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in  rtje  Citp  of  ^eto  |9orfe 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


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CLINICAL  DIAGNOSIS: 


A  HANDBOOK 


STUDENTS  AXD  PRACTITIONERS  OP  MEDICINE. 


EDITED  Br 

JAMES  FINLAYSOX,  M.D., 

PHrSICIAS  ASD  LECTtJKER  OX  CLISICAL  MEDICIXE    I2f  THE  GLASOrOW  WESTEEIT 
lAPIRMAKT  ;    ESAMISEK    IN    ClISICAL    MEDICINE   TO    THE    FACULTY    OF 
PHYSICIANS    AND   SURGEONS,    GLASGOW;   SBCRETARr   OF   THB 
GLASGOW    PATHOLOGICAL    AND    CLINICAL    SOCIETY; 
FORMERLY    HOCSE    STEGEON    TO    THE    MAN- 
CHESTER  CLINICAL    HOSPITAL    AND 
DISPENSARY  FOR  CHILDREN, 
ETC.  ETC.  ETC. 


WITH    ErCxHTY-FIYE    ILLU  S  TR  A  TIOX; 


PHILADELPHIA: 

HENRY      C.LEA. 
1878. 


COLLINS,     PRINTER. 


LIST  OF  CONTRIBUTORS  AND  THEIR  SUBJECTS. 


W.  T.  G-AIRDNER,  M.D.,  Professor  of  the  Practice  of  Physic  in  the 
University  of  Glasgow:  Physician  to  the  Glasgow  Western 
Infirmary,  &c. 

On  The  Phtsiogxomt  of  Disease. 

JAMES  FINLAYSON,  M.D.,  Physician  and  Lecturer  on  Clinical 
Medicine  in  the  Glasgow  Western  Infirmary,  &c. 

On  CASE-TAKHfG,  Family  History,  &c. 
On  Stmptoms  of  Disorder  rx  the  various  Systems. 
(Except  in  so  far  as  specified  below.) 

WILLIAM  STEPHENSON,  M.D.,  Regius  Professor  of  Midwifery  in 
the  University  of  Aberdeen. 

On  Disorders  of  the  Female  Orgaxs. 

ALEXANDER  ROBERTSON,  M.D.,  Physician  and  Superintendent 
of  the  Town's  Hospital  and  City  Parochial  Asylum,  Glasgow. 

On  IXSA>'ITT. 

SAMSON  GEMMELL,  M.B.,  Assistant  to  the  Professor  of  the  Prac- 
tice of  Physic  in  the  University  of  Glasgow,  and  Physician  to 
the  Dispensary  of  the  Glasgow  Western  Infirmary. 

On  The  Sphygmograph. 

On  The  Physical  Exa.iii>'Atiox  of  the  Chest  a>-d  AsDOiiEN. 

JOSEPH  COATS,  M.D.,  Pathologist  and  Lecturer  on  Pathology  in 
the  Glasgow  Western  Infirmary,  and  also  Physician  to  the  Dis- 
pensary and  its  Throat  Department. 

On  The  Exam:inatios  of  the  Fauces,  Larynx,  a>'d  Nares. 
On  The  Method  of  Pekformixg  Post-Mortem  Examinations. 


PREFACE. 


"While  engaged  in  assisting  Professor  Gairdner  in  con- 
ducting his  Clinical  Classes  in  tlie  Glasgow  Royal  Infirmary, 
and  also  in  my  own  work  at  the  Western  Infirmary  here,  the 
want  has  often  been  felt  of  some  volume  to  which  students 
might  be  referred  for  assistance  in  the  study  and  reporting 
of  medical  cases.  The  methods  of  case-taking  sketched  out 
by  various  teachers  are  no  doubt  useful  in  their  way  ;  but 
they  do  not  give  the  amount  or  the  kind  of  assistance  really 
required  in  the  investigation  of  a  difficult  case. 

It  is  common  to  find  that  at  the  bedside  of  a  patient  the 
observer  fails  to  apply  the  knowledge  he  actually  possesses ; 
it  does  not  occur  to  him  to  follow  up  the  inquiry  by  the 
necessary  methods ;  although  he  may  be  perfectly  familiar 
with  them,  he  may  not  think  of  them  at  the  time,  or  at  least 
he  may  fail  to  recognize  their  importance  for  the  case  on  hand. 

This  Manual,  however,  does  not  aim  at  supplying  an  easy 
and  certain  method  of  making  a  diagnosis.  It  would  be 
strange,  indeed,  if  any  book  could  teach  a  student  to  do  that 
which  the  most  accomplished  physician  is  often  unable  to 
complete  to  his  own  satisfaction.  But  one  well-trained  in 
clinical  observation,  if  unable  to  make  a  diagnosis,  can  at 
least  examine  his  patient  thoroughly,  and  it  is  in  this  respect 
that  he  has  an  immense  advantage  :  the  case  is  thus  put  in  a 
fair  way  for  a  diagnosis  whenever  this  becomes  possible. 

It  seemed  quite  within  the  scope  of  a  book  to  give  some 
assistance  in  this  clinical  study  of  the  signs  and  symptoms 
of  disease,  by  supplying  carefully  selected  data  in  a  condensed 
form,  by  submitting  accurate  methods  of  investigation,  by 

A* 


VI  PREFACE. 

pointing  out  probable  fallacies,  and  by  directing  atl<.'ntion  to 
collateral  inquiries  or  issues  which  might  otherwise  be  readily 
overlooked  by  the  inexperienced. 

If  some  such  assistance  could  be  given,  wathin  one  volume 
of  convenient  size,  it  seemed  also  that  our  teaching  at  the 
bedside  might  be  relieved  of  an  enormous  mass  of  detail, 
which  is  apt  at  present  to  interfere  with  the  higher  forms  of 
clinical  instruction  and  research  :  the  importance  of  these 
elementary  details  is  so  great  that  they  cannot  be  omitted, 
or  neglected  in  any  way,  in  the  teaching  of  large  numbers, 
w^ithout  disastrous  results. 

In  attempting  to  produce  such  a  volume  as  is  here  indicated, 
it  was  found  expedient  to  apply  to  several  contributors.  Dr. 
Samson  Gemmell  has  written  the  portion  dealing  with  Physi- 
cal Diagnosis :  from  his  official  position  he  was  able  to  make 
free  use  of  Professor  Gairdner's  lectures  and  teaching  on  this 
subject :  he  has,  likewise,  prepared  a  short  section  on  the 
Sphygmograph,  to  which  instrument  he  has  devoted  some 
special  attention.  In  making  arrangements  for  that  part  of 
the  work  which  involved  the  detailed  discussion  of  the  symp- 
toms of  disease  in  the  various  Systems,  it  soon  became  evi- 
dent to  the  Editor  that  it  would  be  very  desirable  to  obtain 
the  assistance  of  experts  in  special  departments,  if  the  best 
results  were  to  be  aimed  at.  Professor  Stephenson,  accord- 
ingly, agreed  to  deal  with  the  important  department  of  Female 
Disorders  ;  and  Dr.  Joseph  Coats  undertook  the  section  on 
Laryngoscopy  and  Diseases  of  the  Throat.  With  the  devel- 
opment of  the  work  it  seemed  desirable  to  add  a  chapter  on 
Insanity,  on  account  of  the  growing  importance  now  attached 
to  this  branch  of  medicine,  and  also  on  account  of  the  need 
which  students  feel  of  some  guide  in  approaching  cases  of 
mental  derangement ;  this  portion  of  the  book  has  been  fur- 
nished by  Dr.  Alexander  Robertson.  But  in  the  special 
sections  of  this  work,  thus  committed  to  different  hands,  the 
writers  kindly  agreed  to  keep  steadily  in  view  the  relation  of 
the  departments  undertaken  by  them  to  the  general  scheme 


PREFACE.  Vll 

of  the  book ;  and  so  to  keep  the  description  of  mere  details 
in  subordination  to  those  aspects  of  disease  important  in  an 
ordinary  physician's  practice  :  indeed  the  space  available  for 
these  subjects  forbade  any  attempt  to  deal  with  them  in  full 
detail.  Certain  parts  of  the  clinical  investigation  were  likely 
to  be  neglected  in  the  plan  of  such  a  book,  if  a  more  general 
view  of  the  aspect  and  physiognomy  of  the  patient  were 
not  also  supplied  :  to  meet  this  want  an  introductory  chapter 
on  the  Physiognomy  of  Disease  has  been  furnished  by  Pro- 
fessor Gairdner,  who  has  througliout  given  much  assistance 
in  the  rest  of  the  work.  A  concluding  chapter  on  the  Method 
of  performing  Post-mortem  Examinations  has  been  added  by 
Dr.  Joseph  Coats  :  imperfect  methods  of  examining  the  body 
after  death  often  lead  to  the  practical  loss  of  most  important 
and  laborious  clinical  investigations. 

No  attempt  has  been  made  to  follow  out  any  very  strict 
nosological  plan  or  classification  of  subjects.  The  guiding 
considerations  have  always  been  convenience  and  utility. 
The  limitations  of  space  forbade  any  attempt  to  deal  with  the 
treatment  of  disease,  although  occasional  allusions  are  to  be 
found  to  the  effect  of  remedies.  When  the  nature  of  a  case 
has  been  thoroughly  mastered,  so  as  to  afford  a  trustworthy 
guidance  to  its  position  in  respect  of  a  true  diagnosis,  the 
whole  literature  of  medicine  is  laid  open  for  our  assistance 
in  the  treatment. 

Many  portions  of  this  book  are  adapted  more  for  reference 
than  for  reading  in  a  continuous  manner ;  but  others,  it  will 
be  easily  seen,  can  be  read  best  in  sequence.  Some  subjects 
are  dealt  with  more  fully  than  othei-s  :  this  has  been  deter- 
mined, in  large  measure,  by  considering  what  were  the  parts 
of  the  clinical  inquiry  in  which  the  student  required  most 
assistance,  or  in  which  his  present  books  seemed  defective 
for  clinical  purposes. 

Some  references  have  been  given  at  the  openings  of  most 
of  the  chapters  for  the  benefit  of  beginners,  who  might  not 
know  the  names  of  special  treatises  dealing  with  the  various 


Vm  PREFACE. 

subjects  in  detail.  To  prevent  repetition  of  the  titles,  a  list  of 
these  is  given  separately  after  the  table  of  Contents.  It  has 
not  been  thought  desirable,  as  a  rule,  to  cite  authorities  for  the 
statements  in  the  text.  Numerous  references  to  foreign  books 
and  to  periodical  literature  would  have  been  required  in  doing 
so,  and  it  was  feared  that  these  would  only  confuse  many 
readers.  Occasionally  a  name  has  been  introduced,  in  special 
circumstances,  for  the  sake  of  clearness,  and  to  avoid  any 
mistakes  which  might  arise  from  such  an  omission.  In  the 
absence  of  such  citations,  care  has  been  taken,  in  the  sections 
dealing  with  subjects  on  the  borderland  of  medicine,  to  have 
them  revised  by  those  familiar  with  these  departments. 
Various  friends  have  kindly  done  this,  and  their  names  are 
omitted  here  simply  to  avoid  attaching  a  responsibility  to 
them  which  mere  revision  in  this  way  scarcely  imposes. 

In  the  illustrations  the  aim  has  been  to  supply  those  which 
the  student  is  likely  to  feel  the  want  of  in  his  actual  bedside 
investigations.  To  keep  the  volume  from  being  too  expensive, 
no  attempt  has  been  made  to  illustrate  those  subjects  which 
require  color  for  their  proper  representation  :  it  was  thought 
better  to  omit  such  altogether.  Instruments  have  likewise 
been  omitted:  the  reader  is  supposed  to  be  engaged  in  using 
those  referred  to.  The  illustrations  are  partly  new  and  partly 
borrowed  from  recognized  authorities.  In  particular,  acknow- 
ledgment must  be  made  of  those  obtained  by  the  Publishers 
from  the  valuable  work  of  Dr.  Gee,  and  from  the  well-known 
book  of  my  friend  Dr.  Wm.  Roberts.  Several  have  also  been 
copied  from  Dr.  Gairdner's  Clinical  Medicine.  A  list,  with 
details  of  the  sources  of  the  illustrations,  is  given  elsewhere. 
Dr.  John  Wilson  (whose  illustrations  of  the  cutaneous  para- 
sites are  already  well  known  to  the  profession)  has  supplied 
several  new  microscopic  d^a^s;ings  of  great  value. 

J.  F. 

351  Bath  Crescent,  Glasgow, 
Amjust,  1878. 


CONTENTS. 


CHAPTER  I. 

PAGE 

The  Physiognomy  of  Disease,        ......         25 

CHAPTER  II. 
Examination  and  Reporting  of  Medical  Cases,    ...         53 

CHAPTER  III. 
Tempeeatuke — Pulse — General  Signs  of  Pyrexia,       .         .         68 

CHAPTER  IV. 
Skin — Hair — Nails — Glands — Joints,  ....         91 

CHAPTER  V. 

Examination  of  the  Organs  of  Special  Sense — Subjective 
Disorders  of  the  Special  Senses — Testing  of  Cranial 
Nerves, 128 

CHAPTER  VI. 
Symptoms  of  Disorder  in  the  Nervous  System,     .         .         .       166 

CHAPTER  VII. 
The  Use  of  Electrical  Instruments,    .....       207 

CHAPTER  VIII. 
Insanity,      ..........       224 

CHAPTER  IX. 
Disorders  of  the  Respiratory  and  Circulatory  Systems,    .       255 


X  CONTENTS. 

PAGIS 

CHAPTER  X. 
Examination  op  the  Fauces,  Larynx,  and  Nakes,        .         .       287 

CHAPTER  XI. 
Disorders  of  the  Digestive  System,     .    "     .         .         .         .       303 

CHAPTER  XII. 
Jaundice  and  Dropsy,  .         .         .      ' 332 

CHAPTER  XIII. 

Examination  op  the  Urine  and  the  Significance  of  Uri- 
nary Symptoms,     ........       349 

CHAPTER  XIV. 
Symptoms  connected  with  the  Male  Generative  Organs,     .       396 

CHAPTER  XV. 

Disorders  of  the  Female  Organs,  and  their  relations  to 

the  General  Health,    .         , 399 

CHAPTER  XVI. 

The  Physical  Examination  of  the  Chest  and  Abdomen, 
Part  I. — Lungs  ;  Part  II. — Heart  ;  Part  III. — Ab- 
domen,  429 

CHAPTER  XVII. 

Method  of  Performing  Post-Mortem  Examinations,     .        .       503 


LIST  OF  ILLUSTRATIONS. 


FIG.  PAOE 

1.  Diurnal  range  of  tte  temperatnre  in  hectic  fever,  .  71 

2.  UnnsnallT  liigli  temperature  just  before  death,       .         .  73 

3.  Very  low  temperature  just  before  death,         ...  73 

4.  Gradual  rise  of  temperature  at  the  beginning  of  enteric 

fever,  .........  74 

5.  Temperature  in  tertian  ague,  .....  75 

6.  Remitting  lysis  in  enteric  fever,      .....  76 

7.  Collapse  of  the  temperature  in  phthisis,  simulating  an 

improvement.     Comparison  of  axillary  and  vaginal 
measurements  of  the  terminal  temperatures,       .         .         77 

{These  diagrams  of  temperature  were  obtained  from 
patients  under  Dr.  Finlayson''s  care.) 

8.  Diagram  of  the  various  parts  of  a  pulse-wave  (based  on 

Galabin's  diagram),    .......         83 

9.  Healthy  pulse, 84 

10.  Febrile  or  dicrotic  pulse,         ......  84 

11.  Hyper-dicrotous  pulse,  ......  84 

12.  Pulse  of  aortic  regurgitation,  .....  84 
13  and  14.  Eight  and  left  radial  pulses  from 

cic  aneurism,  showing  a  marked  differ 

sides,  .........         85 

15.  Senile  pulse  or  pulse  of  rigid  arteries,    ....         85 

16.  Irregular  pulse,       ........         85 

17.  Pulse-tracing  from  a  case  of  Bright's  disease,  showing 

increased  arterial  tension,  .....         86 

(  These  pulse-tracings  were  taken  by  Dr.  Gemmell  chiefly 
from  patients  under  the  care  of  Dr.  Gairdner.) 

18.  The  Itch  insect — Acarus  Scabiei.     Female — ventral  as- 

pect.   Drawn  by  Dr.  John  Wilson  from  a  specimen  in 

his  possession,     ........         98 


a  case  of  thora- 
ence  on  the  two 


xii  LIST    OF    ILLUSTRATIONS. 

FIQ.  PACII! 

19.  Pedicnlis  Pubis,  or  Crab  louse,  with  ova  adlieriug  to  tlie 

hair.  Drawn  by  Dr.  John  Wilson  from  a  specimen  in 
Glasgow  Western  Infirmary,        .....       101 

20.  Portion  of  hair  from  a  case  of  Favus — Tinea  Favosa — 

showing  sx->ores  of  vegetable  parasitic  growth — Achorion 
Schonleinii.  Reduced  from  Bazin :  Affections  cutan^es 
parasifaires.     Paris,  1858.     PL  ii.,  Fig.  1,  .         .       104 

21.  Portion  of  hair  from  a  case  of  ringworm — Tinea  Tonsurans 

or  Tinea  Tricopliytina — showing  spores  of  vegetable 
parasitic  growth — Tricop/iijton  Tonsurans.  Reduced 
from  Bazin:    Op.  C«i.,  PI.  ii.  Fig.  2,    ....       104 

22.  Microsporon  Furfur,  the  vegetable  parasite  of  Pityriasis 

versicolor.  From  Dr.  M'Call  Anderson's  Parasitic 
Affections  of  the  Skin,  2d  edition,  London,  1867.  Fig. 
17,      . 116 


Ziemssen's  Motor  Points  for  Localized  Electrization : — 
23.         Front  of  forearm, 


211 
212 
213 
214 
215 
216 


24.  Back  of  forearm, 

25.  Front  of  thigh, 

26.  Back  of  thigh, 

27.  Inner  aspect  of  leg, 

28.  Outer  aspect  of  leg, 

(From  Ziemssen  :  Die  Electriciliit  inder  Medicin,  3d 
edition.  Berlin,  1866.  Figs.  15,  17,  19,  20,  21, 
22.) 

29.  Lung  tissue  obtained  from  sputa  after  digestion  in  caus- 

tic soda.  Drawn  by  Dr.  John  Wilson  from  specimens 
obtained  in  Glasgow  Western  Infirmary,     .         .         .       278 

30.  Oidium  Albicans,  the  vegetable  parasite  of  "Muguet"  or 

"Thrush."     Reduced  from  Ch.  Robin;  Histoire  natu- 

relle  des  vSgetaux  parasites.     Paris,  1853.    PI.  i.  Fig  3,        305 

31.  Sarcince  Ventriculi,  starch  granules,  and  oil  globules,  from 

vomited  matter.  Funke :  Atlas  of  Pliysiological  Che- 
mistry. London  (Cavendish  Society),  1853.  Plate 
vii..  Fig.  4, 313 

32.  Oxyurides  Vermiculares,  female,  natural  size.     Davaine : 

Traite    des    Entozoaires.      2d   edition.      Paris,    1877. 

Fig.  48, 322 

33.  Oxyurides  Vermiculares,  laa.gm&ed  five  times.     A,  male; 

B,  female.  Leuckart :  Die  menschlichen  Parasiten. 
Leipzig,  1876.     Bd.  ii.,  Fig.  175,        ....       322 


LIST    OF    ILLUSTRATIONS.  XIU 

FIO.  PAGE 

34.  Tcenia  Mediocanelkda,  natural  size,  showing  tlie  different 

size  and  sliape  of  the  segments  in  the  various  parts. 
Leuckart :  Die  menscMichen  Parusiten.  Leipzig,  1863. 
Bd.  1.,  Fig.  78, ^  .         .323- 

35.  Proglottides  of  Tcenia  solium,  magnified  twice,  showing 

arrangement  of  uterus.     Leuckart:  Op  Cit.,  Fig.  57,         323 

36.  Proglottis  of   Tcenia  mediocaneUata,   magnified,   showing 

arrangement  of  uterus.     Leuckart:    Op.  C(7.,  Fig.  79,       323 

37.  Head  of  Tcenia  sgUwh  (armed  with  a  circle  of  hooklets), 

showing  two  of  the  four  suckers.  From  Dr.  Cobbold's 
Entozoa.  Lond.,  1864.  Plate  xii.  (Reduced  bj  him 
from  Blanchard), 324 

38.  Head  of  Tcenia  mediocaneUata  (not  armed  with  hooklets), 

showing  two  of  the  four  suckers.  Drawn  from  a  speci- 
men in  the  Glasgow  Royal  Infirmary,  by  Dr.  John 
Wilson, 324 

39.  Notched  teeth — malformation  of  permanent  teeth  found 

in  hereditary  syphilis.  Jonathan  Hutchinson  :  Clini- 
cal Memoir  on  Certain  Diseases  of  the  Eye  and  Ear,  con- 
sequent on  Inherited  Syphilis.  London,  1863.  Plate  i., 
Fig.  8, 328 

40.  Diagram  of  percussion-dulness  in  ascites  while  patient  is 

lying  on  the  back,        .......       340 

41.  Diagram  of  the  position  of  an  ovarian  tumor  of  the  right 

side,  in  various  stages  of  enlargement.  The  shading 
shows  the  percussion-dulness  in  ovarian  dropsy  of  mode- 
rate extent.  Slightly  modified  from  Bright :  Clinical 
Memoirs  on  Abdominal  Tumors  and  Intumescence.  Re- 
printed by  New  Sydenham  Society.  London,  1S60. 
Fig.  23, 340 

42.  Human  Echinococci.     A,  A  group  of  echiuococci  still  ad- 

hering to  the  germinal  membrane  by  their  pedicles, 
magnified  40  times.  B,  An  ec-hinococcus  magnified 
107  times ;  the  head  is  iuvaginated  in  the  caudal 
vesicle ;  a  pedicle  is  attached  to  it.  C,  The  same  com- 
pressed ;  the  head  retracted,  the  suckers  and  the  hooks 
are  seen  in  the  interior.  D,  Echinococcus  magnified 
107  times ;  the  head  is  protruded  from  the  caudal 
vesicle.  E,  Crown  of  hooks  magnified  350  times. 
Davaine :  Traiti  desEntozoaires.  2d  edition.  Paris, 
1877.     Fig.   9.     (The  figure  here  is   borrowed   from 

Dr.  Wm.  Roberts), 346 

B 


xiv  LIST    OF    ILLUSTRATIONS. 

FIG.  PAGE 

43.  Crystals  of  cholesterine.     Otto  Funke  :  Atlas  of  Physiolo- 

gical Chemistry.     London,  1853.     Plate  vi.,  Fig.  1,      .       347 

44.  Blood  corpuscles  in  urine.     Dr.  Wm.  Roberts  :  Practical 

treatise  on  urinary  and  renal  diseases,  including  urinary 
deposits.     3d  edition.     London,  1876.     Fig.  30,  .         .       368 

45.  Pus  corpuscles  in  urine.     Dr.  Win.  Roberts :   Op.  Git., 

Fig.  29, 371 

46.  Hyaline  or  waxy  tube-casts.    Dr.  Wm.  Roberts  :  Op.  Cit., 

Fig.  26, 374 

47.  Epithelial  and  opaque  granular  tube-casts.     Dr.  Wm. 

Roberts  :   Op.  Cit.,  Fig.  25, 375 

48.  Fatty  tube-casts   and  blood-casts.     Dr.   Wm.   Roberts  : 

Op.  Cit.,  Fig.  27, 376 

49.  Renal  epithelium.    Dr.  Wm.  Roberts  :   Op.  Cit.,  Fig.  24,       377 

50.  Epithelial  cells  from  the  bladder,  ureter,  and  pelvis  of 

the  kidney.     Dr.  Wm.  Roberts  :   Op.  Cit.,  Fig.  23,     .       378 

51.  Vaginal  epithelium  in  urine.     Dr.  Wm.  Roberts  :   Op. 

Cit.,  Fig.  22, 378 

52.  Spermatozoa.     Dr.  Wm.  Roberts  :    Op.  Cit.,  ¥ig.  35,        .  379 

53.  Vibriones  in  urine.   Dr.  Wm.  Roberts  :  Op.  Cit.,  Fig.  36,  379 

54.  Mould  fungus  (Penicilium  Glaucim)  in  urine.     Dr.  Wm. 

Roberts  :   Op.  Cit.,  Fig.  37, 379 

55.  Yeast  fungus   {Torula    Cerevisiw)   in   urine.     Dr.   Wm. 

Roberts  :   Op.  Cit.,  Fig.  39, 380 

56.  Extraneous  matters  found  in  urine  : — Cotton  fibres,  flax 

fibres,  hairs,  air-bubbles,  oil  globules,  wheat  starch, 
potato  starch,  rice  starch  granules,  vegetable  tissue, 
muscular   fibres,   feathers.     Dr.  Wm.  Roberts  :    Op. 
■      Cit.,  Fig.  2, 381 

57.  Uric  acid  crystals  of  various  forms.     Selected  from  Otto 

YvLiike's  Atlas  of  Physiological  Chemistry.  London,  1853,       382 

58.  Hedgehog  crystals  of  urate  of  soda.     Dr.  Wm.  Roberts: 

Op.  Cit.,  Fig.  10, 383 

59.  Amorphous  urates.    Dr.  Wm.  Roberts:   Op.  Cit.,  Fig.  8,       383 

60.  Ammonio-magnesian    (or    triple)    phosphates,    selected 

from  various  sources  to  show  the  different  forms,         .       384 

61.  Crystallized  phosphate  of  lime,  selected  to  show  the  dif- 

ferent foi'ms,        ........       385 

62.  Crystals  of  oxalate  of  lime,  selected  to  show  the  difi'erent 

forms,  .........       386 


LIST    OF    ILLUSTRATIONS.  XV 

FIG.  PAGE 

63.  Apjohii's  apparatus  for  the  estimatioii  of  tirea  with  the 

hypobromite  of  soda  solution.  For  original,  see  Chem- 
ical News,  Jan.  22,  1875.  (The  figure  here  is  bor- 
rowed from  Dr.  Wm.  Roberts) ,   .         .         .         .         .393 

64.  Transverse  section  of  healthy  chest  upon  level  of  sterno- 

xlphoid  articulation.  Dr.  Samuel  Gee :  Auscultation 
and  Percussion,  together  with  the  other  methods  of  j)ht/sical 
examination  of  the  chest.  2d  edition.  London,  1877. 
Fig.  1, 432 

65.  Pigeon-breast.     Tracing   taken    from   a  cliild  of  seven 

years.     Dr.  Gee :   Op.  Cit.,  Fig.  4,      .         .         .         .       432 

66.  Rickety  chest.     Dr.  Gee :   Op.  Cit.,  Fig.  5,     .         .         .       432 

67.  Bilateral  enlargement  of  emphysema.     Dr.   Gee  :     Op. 

Cit.,  Fig.  7,         .         .         .     ' 433 

68.  Unilateral  retraction  of  chest :  consequent  upon  cirrhosis 

of  left  lung  in  a  girl  of  fourteen.     Dr.  Gee:    Op.  Cit., 

Fig.  9, 434 

69.  Normal  percussion-dulness  of  heart,  liver,  and  spleen, 

Modified  from  Weil :  Handhuch  und  Atlas  der  topogra- 
phischen  Percussion.     Leipzig,  1877,      ....       452 

70.  Percussion-dulness  in  a  case  of  hypertrophy  of  both  sides 

of  the  heart.  (From  a  patient  of  Dr.  Gairdner's,  in- 
troduced on  Weil's  model  of  the  chest),       .         .         .       457 

71.  Percussion-dulness  in  pericardial   effusion.     The  lower 

and  left  margins  are  undefined,  owing  to  their  being 
inseparable  from  the  dull  percussion  of  the  abdomen 
and  of  the  left  pleura.  Dr.  W.  T.  Gairdner  :  Clinical 
Medicine.     Edin.,  1862.     Fig.  30,         ...         .       458 

72.  Displacement   of  mediastinum,   heart,    and   liver   from 

pneumothorax  of  the  right  side.  Weil :  Op.  Cit., 
Plate  xxiii.,         ......•■       459 

73.  Displacement  of  mediastinum,  heart,  and  left  lobe  of 

liver  from  pleuritic  efi"u3ion  on  the  left  side  :  the 
shading  indicates  the  extent  of  the  dull  percussion. 
(Diagram  obtained  from  a  patient  of  Dr.  Gairdner's 
introduced  on  Weil's  model  of  the  chest), 

74.  Diagram  of  the  heart's  action, 

75.  Auricular  systolic  murmur,     . 

76.  Ventricular  systolic  murmur, 

77.  Ventricular-diastolic  murmur. 


460 

462 
466 

467 

467 


XVI  LIST    OF    ILLUSTRATIONS. 

FIO.  PAOE 

78.  Auricular-systolic    and    ventricular-systolic     murmurs 

combined,   .........       467 

79.  Ventricular-systolic  and  ventricular-diastolic  murmurs 

combined,  .         .  .......       468 

80.  Auricular-systolic,  ventricular-systolic,  and  ventricular- 

diastolic  murmurs  combined,       .....       468 
(These  7  diagrams  are  from  Dr.  Gairdner's  Clinical 
Medicine,  Figs.  19  to  24,  pp.  575—579.) 

81.  Diagram  illustrative  of  the  distinctive  areas  of  the  four 

valvular  murmurs.  The  figure  is  borrowed  from  Dr. 
Gairdner's  Clinical  Medicine  (Fig.  25,  p.  583)  :  he  is 
resj)onsible  for  the  areas  marked  out.  The  anatomical 
figure  was  copied,  on  a  reduced  scale,  from  Luschka  : 
Die  Brust- Organe  cles  Menschen  in  ihrer  Lage.  Tii bingen , 
1857, 470 

82.  The  anatomical  regions  of  the  abdomen,  .         .         .       478 

83.  Abdominal  viscera  in  situ,   after  removal  of  omentum. 

Abdominal  portion  copied  from  Marshall :  Physiological 
Diagrams  (No.  3,  Fig.  1),    .         .         .         .         .         .       479 

84.  Displacement  of  cardiac  and  hepatic  dulness  in  emphy- 

sema of  the  lungs.     Weil:    0/j.  C'«V.,  Plate  XXV.,         .       486 

85.  Various  degrees  of  enlargement  of  the  spleen.     Weil : 

Op.  Cit.,  Plate  xvii.  (The  splenic  boundaries  are 
copied  as  they  stand ;  the  cardiac  and  hepatic  are 
slightly  modified), 492 


LIST   OF  WORKS 

Referred  to  in  the  various  chapters  of  the  book  as  suitable  for  con- 
sultation. (Books  in  the  English  language  only  are  here  given  : 
further  references  to  the  bibliography  of  the  subjects  are  to  be 
found  in  most  of  the  siaecial  memoirs  mentioned  below.) 

GENERAL  TREATISES. 

Aitken  (Wm.),  The  Science  and  Practice  of  Medicine.  2  vols.,  6th 
edition,  London,  1872.     (7th  edition  in  the  press.) 

Bristowe  (J.  S.),  A  Treatise  on  the  Theory  and  Practice  of  Medicine, 
London,  1876. 

Flint  (Austin),  A  Treatise  on  the  Princii^les  and  Practice  of  Medi- 
cine.    3d  edition,  Philadelphia,  1868. 

Niemeyer  (Felix  von),  A  Text-Book  of  Practical  Medicine.  New 
edition,  London,  1873. 

Roberts  (F.  T.),  Handbook  of  the  Theory  and  Practice  of  Medicine. 
2  vols.,  3d  edition,  London,  1877. 

Tanner  (Thos.  H.),  The  Practice  of  Medicine,  7th  edition,  edited  by 
Dr.  Broadbent,  London,  1875. 

Trousseau  (A.),  Lectures  on  Clinical  Medicine.  5  vols.  (New  Syden- 
ham Society),  London,  1868-72. 

Watson  (Sir  Thos.),  Lectures  on  the  Principles  and  Practice  of 
Medicine.     5th  edition,  London,  1871. 

Wood  (Geo.),  Treatise  on  the  Practice  of  Medicine.  2  vols.,  Phila- 
delphia, 1852,  and  subsequent  editions. 

Ziemssen's  Cyclopaedia  of  Medicine.  Not  yet  completed,  but  the 
translation  is  now  being  published  (special  volumes  are  referred 
to  under  some  of  the  chapters  of  this  book).  London,  1875, 
and  onwards. 

Reynolds  (J.  Russell),  A  System  of  Medicine.     Vol.  1  (2d  edition, 

London,  1870),  General  Diseases;  vol.  2  (2d  edition,  London, 

1872),   Diseases  of  the  Nervous  System  and  Diseases  of  the 

Stomach  ;  vol.  3  (London,  1871),  Diseases  of  the  Mcuth,  Fauces, 

B* 


XVni  LIST    OP    WORKS. 

Pliarynx,  (Esopliagus,  Intestines,  Peritoneum,  Liver,  and  Pan- 
creas ;  Diseases  of  the  Respiratory  System  (Larynx,  and  the 
Thoracic  Organs)  ;  voL  4  (London,  1877),  Diseases  of  the 
Heart  ;  vol.  5  in  the  press. 

Holmes  (T.),  A  System  of  Surgery  Theoretical  and  Practical,  in 
treatises  by  various  authors.  5  vols.,  2d  edition,  London, 
1870.  Vol.  1,  General  Pathology  ;  vol.  2,  Genercal  and  Special 
Injuries  ;  vol.  3,  Diseases  of  the  Eye  and  Ear,  of  the  Organs  of 
Circulation,  Muscles,  and  Bones  ;  vol.  4,  Diseases  of  the  Organs 
of  Locomotion,  of  Innervation,  of  Digestion,  of  Respiration, 
and  of  the  Urinary  Organs ;  vol.  5,  Diseases  of  the  Genital 
Organs,  of  the  Breast,  Thyi'oid  Gland,  and  Skin.  Operative 
Surgery.     Appendix  of  Miscellaneous  subjects  and  index. 

(Other  surgical  works  may  be  referred  to,  but  details  of  the  above 
are  given,  as  this  book,  from  its  fulness,  has  a  special  value 
to  the  physician.) 

DISEASES  OF  CHILDREN. 

Hillier  (Thos.),  Diseases  of  Children  :  a  clinical  treatise.  London, 
1868. 

Guersant  (M.  P.),  Surgical  Diseases  of  Infants  and  Children 
(Translation).     London,  1873. 

Holmes  (T.),  The  Surgical  Treatment  of  the  Diseases  of  Infancy 
and  Childhood.     2d  edition,  London,  1869. 

Meigs  and  Pepper,  Practical  Treatise  on  Diseases  of  Children.  4th 
edition,  Philadelphia,  1870. 

Smith  (Eustace),  The  Wasting  Diseases  of  Childhood.  2d  edition, 
London, 1870. 

Smith  (J.  Lewis),  On  the  Diseases  of  Infancy  and  Childhood. 
Philadelphia,  1869,  and  subsequent  editions.      , 

Steiner  (Johann),  Compendium  of  Children's  Diseases,  translated 
by  Lawson  Tait,  Loudon,  1874. 

Tanner  (T.  H.),  A  Practical  Treatise  on  the  Diseases  of  Infancy 
and  Childhood.     2d  edition  by  Alfred  Meadows,  London,  1870. 

Vogel  (Alf.),  Practical  Treatise  on  Diseases  of  Children  (Transla- 
tion).    London,  1870. 

West  (Chas.),  Lectures  on  the  Diseases  of  Infancy  and  Childhood. 
6tli  edition,  London,  1874. 

Trousseau's  Clinical  Lectures  should  also  be  consulted  on  this  de- 
partment. 


LIST    or    WORKS. 


SPECIAL  TREATISES. 


Adams  (Robert),  A  Treatise  on  Rheumatic  Gout,  or  Chronic  Rheu- 
matic Arthritis  of  all  the  Joints.     2d  edition,  London,  1873. 

AUbutt  (T.  C),  On  the  Use  of  the  Ophthalmoscope  in  Diseases  of 
the  Nervous  System  and  of  the  Kidneys,  also  in  certain  other 
general  disorders.     London,  1871. 

Althaus  (Julius),  Diseases  of  the  Nervous  System.    London,  1877. 

Treatise  on  Medical  Electricity.     3d  edition,  London,  1873. 

Anderson  (Dr.  McCall),  On  the  Parasitic  Affections  of  the  Skin. 
2d  edition,  London,  1868. 

A  Practical  Treatise  on  Eczema.     2d  edition,  London,  1867. 

On  Psoriasis  and  Lepra.     London,  1865. 

On  the  Ti-eatment  of  Diseases  of  the  Skin,  with  an  analysis 

of  11,000  consecutive  cases.     London,  1872. 

Clinical  Lectures.     London,  1877. 


Anstie  (F.  E.),  Neuralgia  and  Diseases  that  resemble  it.  London, 
1871  (also  in  Reynolds's  System,  vol.  II.). 

Atlas  of  Portraits  of  Skin  Diseases.  New  Sydenham  Society,  London. 

Atlee  (W.  L.),  General  and  Differential  Diagnosis  of  Ovarian  Tu- 
mors.    Loudon,  1873. 

Balfour  (Geo.  W.),  Clinical  Lectures  on  Diseases  of  the  Heart  and 
Aorta.     London,  1876. 

Barnes  (Robert),  A  Clinical  History  of  the  Medical  and  Surgical 
Diseases  of  Women.     2d  edition,  London,  1878. 

Bateman  (F.),  On  Aphasia  or  Loss  of  Speech,  and  the  Localization 
of  the  Faculty  of  Articulate  Language.     London,  1870. 

Beale  (L.),  Kidney  Diseases,  Urinary  Deposits,  and  Calculous  Dis- 
orders, their  nature  and  treatment.    3d  edition,  London,  1869. 

Also,  Plates  separately.     2d  edition,  London,  1869. 

Blandford  (G.  F.),  Insanity  and  its  Treatment;  Lectures  on  the 
treatment,  medical  and  legal,  of  insane  patients.  Edinburgh, 
1871. 

Bright  (R.),  Clinical  Memoirs  on  Abdominal  Tumors  and  Intumes- 
cence.    (New  Sydenham  Society.)     London,  1860. 

Brinton  (Wm.),  Lectures  on  the  Diseases  of  the  Stomach.  2d  edi- 
tion, London,  1864. 

Intestinal  Obstruction.  Edited  by  T.  Buzzard,  London,  1867. 

Browne  (Lennox),  The  Throat  and  its  Diseases,  with  100  typical 
illustrations  in  color,  and  50  wood  engravings.    London,  1878. 

Bucknill  &  Tuke,  Manual  of  Psychological  Medicine.  3d  edition, 
London,  1874. 


XX  LIST    OP    WORKS. 

Carter  (R.  B.),  On  Defects  of  Vision  which  are  reniediaWe  by  Op- 
tical Apjiliances.     London,  1877. 

A  Practical  Treatise  on  the  Diseases  of  the  Eye.     London, 

1875. 

Chambers  (Tlios.  K.),  The  Indigestions  or  Diseases  of  the  Digestive 
Organs,  functionally  treated.     London,  1876. 

Charcot  (J.  M.),  Lectures  on  the  Diseases  of  the  Nervous  System. 
(New  Sydenham  Society.)     London,  1877. 

Cobbold  (T.  S.),  Entozoa  :  an  introduction  to  the  study  of  Helmin- 
thology.     2  vols.  (Plates),  London,  1864-39. 

Worms,  a  series  of  Lectures  on  Practical  Helminthology. 

London,  1872. 

Cohen  (J.  S.),  Diseases  of  the  Throat,  a  guide  to  the  diagnosis  and 
treatment  of  affections  of  the  Pharynx,  (Esophagus,  Trachea, 
Larynx,  and  Nares.     London,  1872. 

Coles  (Oakley),  The  Teeth:  notes  on  their  pathology.  London, 
1872. 

Dalby  (W.  B.),  Lectures  on  Diseases  and  Injuries  of  the  Ear. 
London,  1873. 

Dickinson  (W.  H.),  Diseases  of  the  Kidney  and  Urinary  Derange- 
ments. (Part  I.  Diabetes  ;  Part  II.  Albuminuria  ;  Part  III. 
other  Affections  of  the  Kidney,  &c.)     London,  1875-78. 

Duchenne,  Localized  Electrization.  Translated  by  Herbert  Tibbits. 
Part  I.  Methodology;  Part  II.  Pathology  (preparing).    London. 

Fenwick  (Samuel),  The  Morbid  States  of  the  Stomach  and  Duode- 
num.    London,  1868. 

Fox  (Tilbury),  Skin  Diseases;  their  description,  pathology,  diag- 
nosis, and  treatment.     3d  edition,  London,  1873. 

Atlas  of  Skin  Diseases.     London,  1877. 

Fox  (Wilson),  The  Diseases  of  the  Stomach.  London,  1872.  (Also 
in  Reynolds's  System,  vol.  II.) 

Flint  (Austin),  A  Practical  Treatise  on  the  Physical  Exploration 
of  the  Chest,  and  Diagnosis  of  Diseases  of  the  Respiratory  Or- 
gans.    2d  edition,  Philadelphia,  1866. 

The    Physiology  of  Man.     5   vols.,    New  York,    1868-74. 

(Vol.  V.  Organs  of  Sense.) 

Frerichs  (Prof.),  A  Clinical  Account  of  Diseases  of  the  Liver.  (New 
Sydenham  Society.)     2  vols.,  Loudon,  1862. 

Gairdner  (W.  T.),  Clinical  Medicine.     Edinburgh,  1862. 

Garrod  (A.  B.),  A  Treatise  on  Gout  and  Rheumatic  Gout.  3d  edi- 
tion, London,  1876.     (Also  in  Reynolds's  System,  vol.  I.) 

Garretson  (John  E.),  A  System  of  Oral  Surgery.  Philadelphia, 
1873. 


LIST    OF    WORKS.  xxi 

Gee  (Samuel),  Auscultation  and  Percussion.  2d  edition,  London, 
1877. 

Gibb  (Sir  Geo.  Duncan),  The  Laryngoscope  in  Diseases  of  the 
Throat,  with  a  chapter  on  Rhinoscopy.  3d  edition,  London, 
1868. 

Greenhow  (E.  H.),  On  Addison's  Disease.     London,  1875. 

Griesinger  (Prof.),  A  Manual  of  Mental  Pathology  and  Therapeu- 
tics.    (New  Sydenham  Society.)     London,  1867. 

Hewitt  (Graily),  The  Pathology,  Diagnosis,  and  Treatment  of  Dis- 
eases of  Women,  including  the  Diagnosis  of  Pregnancy.  3d 
edition,  London,  1872. 

Habershon  (S.  0.)  Pathological  and  Practical  Observations  on  Dis- 
eases of  the  Abdomen,  comprising  those  of  the  Stomach  and 
other  parts  of  the  Alimentary  Canal,  (Esophagus,  Caecum,  In- 
testines, and  Peritoneum.     2d  edition,  London,  1862. 

On  the  Diseases  of  the  Stomach,  and  the  varieties  of  Dys- 
pepsia.    London,  1866. 

Hammond  (Wm.  A.),  A  Treatise  on  Diseases  of  the  Nervous  Sys- 
tem.    6th  edition,  London,  1876. 

Hayden  (T.),  The  Diseases  of  the  Heart  and  Aorta.    Dublin,  1875. 

Hebra  (F.),  On  Diseases  of  the  Skin,  including  the  Exanthemata. 
4  vols.  (New  Sydenham  Society),  London,  1866-75. 

Hinton  (Jas.),  Questions  in  Aural  Surgery.     London,  1874. 

Hutchinson  (Jonathan),  A  Clinical  Memoir  on  certain  Diseases  of 
the  Eye  and  Ear,  consequent  on  Inherited  Syphilis.  London, 
1863. 

Ireland  (Wm.),  On  Idiocy  and  Imbecility.     London,  1877. 

James  (Prosser),  Lessons  on  Laryngoscopy,  including  Pihinoscopy ; 
with  colored  illustrations.     2d  edition,  London,  1878. 

1  Sore  Throat,  its  nature,  Varieties,  and  Treatment.  3d  edi- 
tion, London,  1878. 

Kiichenmeister  (Dr.  F.),  On  Animal  and  Vegetable  Parasites  of  the 
Human  Body;  and  Siebold  (C.  T.  von).  On  Tape  and  Cystic 
Worms.     2  vols.  (Sydenham  Society.)     London,  1857. 

Laennec,  Treatise  on  Diseases  of  the  Chest,  their  anatomical  cha- 
racters and  diagnosis,  by  means  of  acoustic  instruments. 
Translated  by  Sir  John  Forbes.     2d  edition,  London,  1827. 

Mackenzie  (Morell),  Essays  on  Growths  in  th«j  Larynx.  London, 
1871. 

The  Use  of  the  Laryngoscope  in  Diseases  of  the  Throat, 

with  an  appendix  on  RhinoscKjpy.     3d  edition,  London,  1871. 
(See  also  article  in  Reynolds's  System,  vol.  III.) 


XXll  LIST    OF    WORKS. 

MacKenzie  (Win.),  Practical  Treatise  on  Diseases  of  the  Eye.  4tli 
edition,  London,  1854. 

Maudsley  (Henry),  Body  and  Mind:  an  inquiry  into  their  connec- 
tion and  mutual  influence  specially  in  reference  to  mental  dis- 
orders.    2d  edition,  London,  1873. 

Meyer  (Moritz),  Electricity  in  its  relation  to  Practical  Medicine. 
Translated  by  W.  A.  Hammond,  New  York,  1869. 

Mitchell  (S.  W.),  Injuries  of  Nerves  and  their  Treatment.  Phila- 
delphia, 1872. 

Montgomery  (W.),  Exposition  of  the  Signs  and  Symptoms  of  Preg- 
nancy.    2d  edition,  London,  1856. 

Murchison  (Chas.),  A  Treatise  on  the  Continued  Fevers  of  Great 
Britain.     2d  edition,  London,  1873. 

Clinical  Lectures  on  Diseases  of  the  Liver,  Jaundice,  and 

Abdominal  Dropsy.     2d  edition,  London,  ]877. 

Neuman  (Isidor),  Text-book  of  Skin  Diseases.    Translated  from  2d 

edition  by  A.  Pullar.     London,  1871. 
Pavy  (P.),  Researches  on  the  Nature  and  Treatment  of  Diabetes. 

2d  edition,  London,  1869. 

Practical  Treatise  on  the  Function  of  Digestion.     London, 

1869. 

Peaslee  (E.  R.),  Ovarian  Tumors,  their  Pathology,  Diagnosis,  and 
Treatment.     London,  1873. 

Poore  (Geo.  V.),  A  Text-book  of  Electricity,  in  Medicine  and  Sur- 
gery.    London,  1876. 

Roberts  (Wm.),  A  Practical  Treatise  on  Urinaiy  and  Renal  Dis- 
eases, including  Urinary  Deposits.     3d  edition,  London,  1877. 

On  Spontaneous  Generation  and  the  Doctrine  of  Contagium 

.    Vivum.     London,  1877.     (See  also  British  Medical  Journal,  Au- 
gust, 1877.) 

Clinical  Pocket-book.     London,  Smith,  Elder  &  Co.,  1874. 


Roosa  (D.  B.  St.  J.),  A  Practical  Treatise  on  Diseases  of  the  Ear, 
including  the  Anatomy  of  the  Organ.     New  York,  1873. 

Salter  (Hyde),  On  Asthma,  its  Pathology  and  Treatment.  2d  edi- 
tion.    London,  1868. 

Sanders  (W.  R.),  Method  of  Examining  and  Recording  Medical 
Cases.  Maclachlan&  Stewart,  Edinburgh,  1873  (Reprint  from 
Edinburgh  Medical  Journal,  November,  1873). 

Sansom  (A.  E.),  Lectures  on  the  Physical  Diagnosis  of  Diseases  of 
the  Heart.     London,  1876. 

Simpson  (Sir  James),  Clinical  Lectures  on  the  Diseases  of  Women, 
Edinburgh,  1872. 


LIST    OF    WORKS  XXlll 

Skoda  (Joseph),  On  Auscultation.  Translated  by  Dr.  Markham, 
London,  1853. 

Stewart  (T.  Grainger),  A  Practical  Treatise  on  Bright's  Disease  of 
the  Kidneys.     2d  edition,  Edinburgh,  1871. 

Thtidicum  (J.  L.  W.),  A  Treatise  on  the  Pathology  of  the  Urine, 
including  a  complete  guide  to  its  analysis.  2d  edition,  London, 
1877. 

Tibbits  (H.),  A  Handbook  of  Medical  Electricity.  2d  edition, 
London. 

Thomas  (T.  Gaillard),  A  Practical  Treatise  on  the  Diseases  of 
Women.     Philadelphia,  1868,  and  subsequent  editions. 

Von  Troeltsch,  The  Surgical  Diseases  of  the  Ear.  (New  Sydenham 
Society.)     London,  1874. 

Walshe  (W.  H.),  Practical  Treatise  on  Diseases  of  the  Lungs,  in- 
cluding the  principles  of  their  physical  diagnosis.  4th  edition, 
London,  1871. 

Practical  Treatise  on  Diseases  of  the  Heart  and  Great  Ves- 
sels, including  the  principles  of  their  physical  diagnosis.  4th 
edition,  London,  1873. 

Walton  (Haynes),  A  Practical  Treatise  on  Diseases  of  the  Eye.  3d 
edition,  London,  1875. 

Waters  (A.  T.  H.),  On  Diseases  of  the  Chest.  2d  edition,  London, 
1873. 

Watts,  Dictionary  of  Chemistry  and  the  allied  branches  of  other 
sciences.  5  vols.  New  edition,  London,  1874.  Supplement, 
London,  1872.     Supplement,  Vol.  II.,  London,  1875. 

Wedl  (Carl),  The  Pathology  of  the  Teeth.  (Translation.)  Phila- 
delphia, 1873. 

Wells  (J.  Soelberg),  A  Treatise  on  the  Diseases  of  the  Eye.  3d 
edition,  London,  1873. 

Wells  (T.  Spencer),  Diseases  of  the  Ovaries,  their  diagnosis  and 
treatment.     London,  1872. 

West  (Charles),  Lectures  on  the  Diseases  of  Women.  3d  edition, 
London,  1864. 

Some  Disorders  of  the  NervoiTS  System  in  Childhood.  Lon- 
don, 1871. 

Wilks  (Samuel),  Lectures  on  Diseases  of  the  Nervous  System. 
London,  1878. 

Wilson  (Erasmus),  Portraits  of  Diseases  of  the  Skin.  London, 
1847. 

Ziemssen  (H.),  Map  of  Ziemssen's  motor  points  of  the  human  body, 
by  Herbert  Tibbits.     London,  1877. 


CLINICAL  DIAGNOSIS. 


CHAPTER  L 

THE  PHYSIOGNOMY  OF  DISEASE. 

In  examining  for  medical  purposes  a  patient  affected  with 
some  bodily  disease,  it  is  of  importance  for  the  inquirer  to 
have  before  his  mind  from  the  first  the  nature  and  the  scope 
of  the  inquiry  proposed,  and  not  to  be  misled  by  any  of  the 
merely  conventional  phrases  or  forms  of  thought  under  which 
plausible  fallacies  and  rash  generalizations  are  so  prone  to 
hide  themselves.  This  remark  applies  with  peculiar  force 
to  the  investigation  of  the  more  external  or  physiognomic 
characters  of  disease,  because  it  is  in  dealing  with  these  that 
the  pliysician  is  under  the  strongest  temptations  to  appear 
wise  at  all  hazards,  and  thus  to  formulate  his  knowledge  (or 
his  ignorance)  under  terms  whicli  may  or  may  not  be  correct 
as  regards  the  individual  case  before  him,  but  of  which  he 
would  find  the  exact  definition  extremely  difficult,  or  impos- 
sible. Thus,  it  is  very  easy  in  a  particular  case  to  pronounce 
the  patient  '■'  of  a  phthisical  aspect,"  or  "  of  a  gouty  habit," 
or  "strumous,"  or  of  a  rheumatic  or  other  "diathesis,"  or  to 
say  that  he  has  a  well-marked  "  malignant,"  or  "  cancerous 
cachexy ;"  and  any  one  of  these  expressions  may,  in  the 
particular  case,  indicate  something  that  is  really  true,  while, 
nevertheless,  the  expression  itself  is  altogether  objectionable, 
and  devoid  both  of  real  accuracy  and  scientific  value.  What 
the  clinical  observer  has  to  do  is  not  to  grasp  at  a  hasty 
generalization,  but  to  note  details  of  positive  fact,  and  out  of 
these  to  evolve  the  elements  of  a  sure  diagnosis.  Tlie  state- 
ment that  the  patient  has  some  peculiar  and  specific  consti- 
tutional morbid  tendency  or  bias  is  not,  in  any  case,  the 
statement  of  a  fact,  but  of  an  opinion,  and  sometimes  of  a 
very  insecure  and  fanciful  opinion.  Such  a  statement,  there- 
fore, should  never  be  found  among  the  preliminaries,  pro- 
3 


26  THE    PHYSIOGNOMY    OF    DISEASE. 

bably,  indeed,  rarely  even  in  the  more  advanced  stages,  of 
an  hospital- report ;  inasmuch  as  even  when  true  in  fact,  it  is 
an  inference  based  upon  many,  and  much  simpler,  facts  which 
ought  to  have  be^en  separately  noted.  The  same  principle 
holds,  perhaps  still  more  strongly,  as  regards  the  so-called 
"temperaments" — sanguine,  bilious,  nervous,  etc.,  and  all 
their  more  complex  varieties.  Without  discussing  liere  at 
all  the  amount  of  truth,  or  of  reality,  underlying  these  ex- 
pressions, it  may  be  certainly  affirmed  that  their  relation  to 
particular  diseases  is  almost  wholly  illusory  ;  and,  therefore, 
the  statements  in  which  the  elements  of  a  diagnosis,  so  to 
speak,  are  concerned,  should  be  as  simple  and  precise  as 
possible,  and  should  certainly  not  involve  any  general  doc- 
trine or  theory  of  the  disease  or  of  its  causes. 

Nevertheless,  it  is  quite  true  that  diseases,  considered  as 
disturbances  of  the  physiological  course  of  a  healthy  life,  are 
often  marked  by  incidents  which  leave  indelible  traces  not 
only  in  the  history,  but  on  the  physical  structure  of  the  body; 
and  it  is  the  study  of  these,  properly  speaking,  which  aifords 
to  the  well-informed  physician  almost  the  whole  basis  of  ob- 
jective fact  out  of  which  a  morbid  tendency,  or  diathesis,  can 
be  inferred  with  a  fair  amount  of  probability.  In  other 
words,  diathesis,  as  a  study  of  facts  in  an  individual  case,  is 
an  inference  either  from  previous  facts  in  the  history  indi- 
cating deranged  physiological  function,  or  from  manifest 
structural  changes,  the  result  of  these ;  whereby  we  are 
enabled  to  establish,  but  only  as  a  presumption  founded  with 
more  or  less  probability  on  the  evidence,  the  existence  of  a 
tendency  to  similar  changes,  or  changes  of  some  allied  order, 
in  the  future.  In  other  words,  the  pi'oof  of  diathesis  is  essen- 
tially the  proof  of  disease;  but,  it  may  well  be,  disease  in  its 
earliest  manifestations  and  least  notable  forms. 

There  is  a  whole  group  of  diseases,  for  example,  Avhich 
affect  the  human  body  chiefly  or  exclusively  during  its  period 
of  growth,  whether  of  early  infancy  or  of  adolescence  ;  and 
another  group,  the  first  approaches  of  which  are  usuidly  ob- 
served only  along  with,  or  succeeding,  the  physiological  signs 
of- senile  decay.  As  regards  the  latter  group,  it  may  be  said 
with  truth  that  physiology  and  pathology  are  inextricably 
intermingled.  A  too  early  arcus  senilis,  or  the  premature 
development  of  "crow's  feet"  at  the  outer  margins  of  the 
eyelids,  wrinkles  in  the  skin  of  the  face,  diminished  sensi- 
bility of  the  retina,  or  early  presbyopia ;  still  more,  the  well- 
known  changes  in  the  arteries,  twisting  or  rigidity  of  the 


DIATHESIS — SENILE    DECAY.  ~  21 

radials,  etc. ;  falling  or  grayness  of  the  hair,  diminution  or 
loss  of  sexual  activity,  and  cessation  of  the  catamenia  in 
women ;  all  of  these  (and  yet  perhaps  none  of  them  singly 
and  unsupported  by  the  othei-s)  may  be  appealed  to  as  evi- 
dence of  a  liability  to  diseases  of  the  senile  group  generally; 
and,  if  further  corroborated  by  slight  manifestations  of  actual 
disease,  or  of  organic  changes  the  result  of  disease,  may  form 
considerable  elements  in  the  diagnosis  of  a  diathesis,  as  for 
example,  a  tendency  to  hemorrliagic  apoplexy.  Or  again, 
certain  transverse  markings  upon  the  teetli  (quite  distinct  in 
character  from  those  to  be  afterwards  noticed  as  syphilitic); 
curv^atures,  or  other  alterations  in  the  form  of  the  long  bones, 
and  a  certain  well-known  conformation  of  the  thorax,  may 
indicate  w^ith  the  utmost  precision  disorders  proper  to  the 
period  of  the  first  or  of  the  second  dentition,  when  rickety 
distortion,  with  or  without  bronchitis  and  other  severe  but  not 
permanent  conditions  of  disease  interfering  with  the  free  ex- 
pansion of  the  lungs,  may  have  left  an  impress  upon  the  bony 
skeleton.  So,  too,  it  may  be  remarked  that  the  presence  or 
absence  of  traces  of  past  disease  of  the  bones  and  joints,  or 
of  glandular  enlargements  and  cicatrices  in  the  neck,  or  of 
spinal  disease,  may,  together  with  a  certain  conformation  of 
chest,  or  indeed  of  the  body  generally,  form  part  of  a  chain 
of  circumstantial  evidence,  as  it  were,  tending  to  prove,  or 
to  disprove,  a  liability  to  tubercular  disease  of  the  lungs. 
But  what  has  chiefly  to  be  rooted  out  of  the  mind  of  the  ill- 
informed,  or  imperfectly  trained,  clinical  student  is  the  im- 
pression that  such  conclusions  are  to  be  safely  reached  through 
mere  phrases  appealing  largely  to  the  imagination  without 
minute  and  careful  study  of  details.  The  popular,  and  to  a 
certain  extent  the  half-educated  medical  mind,  is  ahvays 
looking  for  a  pathognomonic  sign,  or  a  broad,  striking,  easy 
generalization  from  a  few  facts;  whereas  it  is  only  by  ripened 
experience  that  we  come  to  know  gradually  the  real  value  of 
common  and  obvious,  still  more,  of  uncommon  and  not  ob- 
vious, facts  lohen  seen  in  combination,  so  as  to  form  con- 
jointly a  basis  for  lai'ge  inferences.  Such  a  diagnosis,  however, 
is  often  the  result  of  the  careful  study  of  the  physiognomic 
characteristics  of  individual  patients. 

In  beginning  the  study  of  this  subject,  it  is  impossible  to 
overlook  the  importance  of  the  iveight  and  size  of  the  body 
as  a  test  of  its  physiological  condition.  Many  diseases,  per- 
haps indeed  all  diseases  attended  by  fever,  and  many  or  most 
of  the  organic  diseases  of  the  viscera,  whether  febrile  or  not, 


28  THE  rHYSIOGNOMY    OF    DISEASE. 

are  characteristically  marked  by  a  loss  of  weight,  Avhich 
often  bears  some  sort  of  relation  to  the  progress  of  the  dis- 
ease, especially  in  cases  that  end  fatallj'.  This  tendency  is 
the  ])hysical  expression  of  a  derangement  of  the  entire  tex- 
tural  nutrition  of  the  body,  ■which,  as  a  rule,  becomes  ap- 
parent externally,  in  the  first  instance,  through  the  gradual 
wasting  of  the  stores  of  fatty  material  in  the  subcutaneous 
layers  and  in  the  interstices  of  the  muscles,  omenta,  orbits, 
etc. ;  but  which  really  carries  as  an  ultimate  result  the  wast- 
ing of  every  texture  in  the  body — the  bones,  the  fibrous 
tissues,  and  the  nervous  centres  being  (according  to  Chossat) 
the  last  to  become  appreciably  altered  in  weight ;  the  brain, 
indeed,  almost  inappreciably,  even  in  an  animal  starved  to 
death.  But  in  morbid  inanition  (as  opposed  to  this  physio- 
logical kind)  there  is  usually  not  only  deficient,  but  altered, 
tissue-formation  ;  so  much  so,  that  while  fat  disappears  from 
all  the  usual  situations  in  which  it  is  normally  stored  up, 
fatty  or  oleo-albuminous  molecules  are  formed  in  tlie  micro- 
scopic elements  of  the  wasting  textures  generally,  and 
chemical  products,  also,  of  decomposition  of  the  nitrogenous 
tissues  are  found  in  excess  in  the  blood,  muscles,  and  glan- 
dular viscera.  And  this  may  take  place  (as  in  diabetes 
mellitus),  when  large  quantities  of  actual  nutritious  matter 
of  various  kinds  are  passed  through  the  organs  of  assimila- 
tion, and  are  even  digested  and  assimilated,  up  to  a  certain 
point,  Avith  preternatural  activity.  In  such  cases  it  has  been 
said,  with  a  certain  amount  of  truth,  that  the  body  becomes 
autophacjous,  or  self-devouring ;  the  muscles  feed  upon  the 
integumentary  tissues,  the  brain  and  nerves  upon  the  mus- 
cles;  the  new  nourishment  conveyed  into  the  system,  if  any, 
being  wasted  and  ]"a[)idly  excreted,  along  with  the  effete 
matter  of  the  wasting  tissues.  Tiiis  state  of  morbid  emacia- 
tion is  most  easily  recognized  in  the  living  patient  by  gradual 
loss  of  weight,  as  well  as  by  the  external  characters  of 
shrinking  and  shrivelling  of  the  soft  tissues,  in  the  order 
indicated  above  as  a  genei-al  rule.  But  loss  of  weight,  as  a 
personal  and  individual  fact,  can  be  exactly  established  only 
by  repeated  weighing  of  the  same  patient  at  intervals ;  and 
in  hospital  wards  this  ought  to  be  done  on  admission,  and 
afterwards  every  week  or  two,  so  as  to  obtain  an  accurate 
view  of  the  progress  of  the  case.  In  private  practice,  among 
men  of  the  well-to-do  classes,  it  is  quite  common,  nowadays, 
to  find  that  the  habitual  or  physiological  weight  of  the  indi- 
vidual, and  even  the  amount  of  variation  in  it  in  the  midst 


BODY-WEIGHT.  ~  29 

of  apparent  good  health,  are  well  enough  known  to  patients 
themselves,  from  actual  weighings  more  or  less  frequently- 
repeated  ;  and  by  availing  ourselves  of  these  spontaneously 
provided  data  we  are  often  able  to  form  a  tolerably  clear  con- 
ception of  the  morbid  changes  present  at  the  time  of  first 
seeing  the  patient.  But  in  other  cases  no  such  data  exist ; 
and  the  "  personal  equation,"  so  to  speak,  of  weight  has  to  be 
adjusted  for  the  individaal  from  more  general  statements,  or 
from  actual  observations  founded  on  averages.  But  this  is 
by  no  means  easy  ;  for  the  limits  of  variation  in  weight  con- 
sistent with  health,  even  in  the  same  individual,  have  yet 
to  be  determined ;  and  tlie  extreme  limits  of  difference  in  a 
number  of  individuals  of  like  stature  are  notoriously  so  wide, 
even  imder  strictly  physiological  conditions,  as  to  render  all 
averages  inapplicable  to  the  extremes.  A  vast  series  of 
observations  by  Dr.  Hutchinson  is,  from  this  cause,  of  com- 
paratively small  value  to  the  clinical  observer  as  furnishing 
a  standard  of  health,  it  being  necessary  to  allow  for  great 
variations  in  both  directions  from  the  mean  weight  corres- 
ponding to  stature ;  but  perhaps  the  following  condensed 
summary  may  be  adopted  as  an  approximation  to  the  actual 
truth  :— 

A  man  of  5  feet  should  weigh  from    8  to  9  stone. 

5  ft.  3  in.  "  9  "10      " 

5  ft.  6  in.  '  "  10  "11      " 

5  ft.  9  in.  "  11  "12i    " 

"         6  ft.  "  12  "14      " 

These  numbers  (as  already  stated)  are  not  to  be  taken  as 
being  more  than  approximations  to  a  normal  standard  of  rela- 
tion, subject  to  considerable  latitude  of  interpretation  in  both 
directions.  In  applying  them  to  an  individual  case  it  will  be 
well  to  ascertain,  as  far  as  possible,  the  life-history  of  the 
patient  in  respect  of  height  and  weight  proportion,  if  not  in 
exact  figures,  at  least  in  such  terms  as  may  be  conventionally 
well  enough  understood  for  practical  purposes.  Supposing, 
for  example,  that  the  patient  is  a  well-grown  man,  verging 
towards  the  "  sere  and  yellow  leaf,"  and  in  advancing  age 
evidently  tending  to  accumulate  fat  in  the  abdominal  wall 
and  elsewhere — Was  he  always  "stout"  (in  the  sense  of  his 
present  condition),  or  was  he,  as  a  youth,  "thin,"  or 
"  slender,"  or  "  wiry,"  or  "alight  weight"?  All  of  these 
are  expressions  well  understood  by  most  men  as  conveying 
easily-appreciable  relations  of  bodily  conformation,  and  the 

3* 


30  THE    PHYSIOGNO^IY    OF    DISEASE. 

last  of  them  miglit  even  lead  to  more  exact  statements  tend- 
ing to  determine  the  precise  time  of  life  when  tlie  sense  of  an 
increasing  burden  of  flesh  became  manifest  as  a  subjective 
fact.  In  the  growing  period  of  the  bodv  it  is  quite  common 
to  saj  of  persons  of  slender  habit,  that  they  "  shot  up  very 
fast,"  /.  e.,  that  the  increase  in  height  did  not  carry  corres- 
ponding breadth  along  -with  it  in  boyhood  ;  and  this  expres- 
sion, or  something  like  it,  is  often  used  by  mothers  a«  indi- 
cating a  fear  or  misgiving  that  the  phthisical  tendency,  either 
as  a  diathesis,  or  even  as  an  actual  disease,  may  have  existed 
or  been  manifested  at  an  early  period  of  life.  "  Wiry," 
again,  is  generally  open  to  a  different  interpretation  ;  it  cor- 
responds, in  a  man,  to  what  in  a  woman  would  be  called 
(but  not,  of  course,  by  herself  or  her  friends)  "scraggy,"  or 
"raw-boned;"  viz.,  a  physical  conformation  in  which  bone 
and  muscle  predominate,  and  the  whole  organization  indicates 
a  robust  and  active  rather  than  a  graceful  or  refined  personal 
presence  ;  but,  nevertheless,  a  bodily  organization  perfectly 
sound  in  essentials,  and  eminently  fit,  from  its  very  hardness 
and  angularity,  to  do  rough  work  in  the  battle  of  life.  "Thin," 
or  "slender,"  in  a  man,  perhaps  conveys  the  trace  of  an  im- 
putation of  physical  inferiority,  or,  on  the  other  hand,  these 
expressions  may  be  perfectly  indifferent  as  regards  previous 
health  or  disease.  The  })hysical  opposites  of  these  bodily 
states,  within  the  limits  of  health,  are  usually  conveyed  by 
the  expressions  "  lusty,"  or  "  stout,"  or  "  in  good  condition," 
and  a  little  good-humored  allusion,  half  in  a  joke,  will  often 
elicit  most  important  facts  Iw  the  physician  ;  indeed,  be- 
ginners would  do  well  to  study  the  facetious  vocabulary  of 
Prince  Hal,  as  applied  to  that  great  impersonation  of  vigor- 
ous and  humorous  rotundity — Falstaff,  in  the  pages  of  Shaks- 
peare.^  In  women,  and  especially  in  those  who  have  still 
reason  to  be  careful  about  appearances,  it  is  necessary  to  take 
care  not  to  give  offence  by  a  too  abrupt  or  coarsely-worded 

-  '  "King  Henry  IV.,"  Part  I.  — Tlie  converse  of  the  character  of 
that  lusty  knight,  who  might  be  supposed  to  be  tlie  original  of  the 
proverb,  "Laugh  and  grow  fat,"  will  be  found  in  Caesar's  remark 
on  Cassins  as  a  probable  conspirator,  and  "dangerous,"  on  account 
of  his  "lean  and  hungry  look,"  his  much  thought  and  reading  ; 
his  keen  penetration  "quite  through  the  deeds  of  men  ;"  and  his 
contempt  of  personal  gratification  and  amusement.  A  perfect  type 
of  what  would  be  styled  in  old  medical  language  the  "  bilious,"  or 
rather  "  atrabilious,"  or  "  melancholic  temperament." — See  "Julius 
Caesar,"  Act  I.,  Scene  2. 


CORPULENCE.  ~  31 

question  ;  but  with  a  little  tact  there  is  no  real  difficulty  in 
getting  at  the  facts  in  a  round-about  way,  and  even  without 
using  the  sickly  French  shmg  of  "embonpoint,"  which  is 
supposed  by  some  to  be  specially  polite  language  as  applied 
to  ladies  of  a  somcAvhat  too  large  and  substantial  physique. 
But  in  all  these  inquiries  and  observations  it  is  to  be  re- 
marked that  the  exjierience  of  years,  and  the  critical  appre- 
ciation of  the  human  form  under  a  great  variety  of  conditions, 
normal  and  abnormal,  gives  to  the  physician  in  many  cases 
a  power  akin  to  that  of  the  artist,  incommunicable  by  words; 
an  instinct  of  divination,  so  to  speak,  by  which  the  true 
character  and  the  history  of  the  organism  may  be  read  in  the 
external  features  and  physical  characteristics  ;  and  this,  not 
only  as  to  health  and  disease,  but  as  to  all  the  leading  ele- 
ments of  character. 

There  is  one  remark  that  will  not,  perhaps,  quite  readily 
occur  to  the  superficial  observer,  but  which  is,  nevertheless, 
of  the  widest  possible  application  to  the  subject  of  body- 
weight,  and  of  the  greatest  significance  in  respect  to  the 
physiognomy  of  disease.  It  is  natural,  perhaps  inevitable, 
to  think  of  great  and  small  body-weight  as  being  really  op- 
posed or  contrasted  conditions,  just  as  we  think  of  giants  and 
dwarfs  as  opposed  or  contrasted  in  respect  of  stature  and 
general  bulk.  But  this  is  a  false,  or  at  least  a  misleading 
analogy ;  for  while  a  son  of  Anak  may  be  in  every  way  as 
healthy  and  as  well  proportioned  as  a  General  Tom  Thumb, 
it  is  impossible  to  look  upon  excessive  any  more  than  defec- 
tive body-weight,  per  se,  as  a  mere  question  of  big  or  little. 
Up  to  a  certain  point,  indeed,  and  within  the  limits  of  strict 
physiological  health,  the  increase  of  bulk  may  be  a  mere 
question  of  degree  ;  e.  g.,  a  man  of  medium  stature  may  be 
140  lbs.  in  weight,  or  he  may  be  180,  or  even,  perhaps,  200 
lbs. ;  if  the  proportion  of  all  the  more  important  or  essential 
bodily  parts  is  fairly  preserved,  e.g.,  of  the  muscles  and  liga- 
ments to  tlie  bones,  of  the  viscera  of  the  chest  and  abdomen 
to  the  external  structure,  and  of  the  cavities  to  the  viscera, 
there  will  not  be  necessarily,  at  least,  any  appreciable  im- 
pairment of  function,  or  any  disease.  But  the  tendency  of 
extremes  in  both  directions  is  very  apt  to  be  towards  im- 
paired function,  and  therefore  towards  actual  or  proximate 
structural  disease.  And  in  the  case  of  excessive  corpidence, 
still  more  than  that  of  excessive  emaciation,  it  may  be  said 
that  the  morbid  tendency,  once  implanted,  is  apt  to  be  pro- 
gressive; the  functions  and  structures  that  are  oppressed  by 


32  THE    PHYSIOGNOMY    OF    DISEASE. 

the  abnormal  growth  of  fatty  tissue  being  thereby  perma- 
nently, though  very  gradually,  altered,  so  that  most  of  the 
tissues  visibly  degenerate,  and  what  seems  at  first  sight  to 
be  an  hypertrophy  of  the  bodily  frame  becomes,  in  a  most 
genuine  and  physiological  sense,  a  true  atrophy  of  some  of 
the  most  important  and  vital  parts  of  it.  Thus,  fatty  atrophy 
of  the  heart,  of  the  secreting  cells  of  the  liver  and  kidney, 
and  of  other  important  organs  and  parts,  is  extremely  com- 
mon in  cases  of  excessive  corpulence ;  and  the  blood  itself, 
there  is  strong  reason  to  think,  undergoes  in  such  cases  a 
kind  of  relative  atrophy,  both  its  amount  and  its  nutritious 
quality  being  more  or  less  impaired.  Hence  the  old  and 
probably  correct  observation  derived  from  the  days  of  large 
blood-lettings,  that  stout  subjects  (in  the  sense  of  corpulent) 
do  not  bear  loss  of  blood  nearly  so  well  as  those  of  more 
slender  bodily  constitution.  It  is  also  notorious  that  such 
subjects  often  succumb  much  more  readily  to  fevers  and  other 
exhausting  diseases  than  those  of  "  wiry"  fi-ame,  or  even  those 
who,  from  defectively  slender  development,  may  have  ap- 
peared to  be  of  a  much  inferior  physique.  It  is  not  at  all 
clear,  therefore,  that  any  amount  of  external  fat  beyond  a 
fair  average  is,  physiologically  speaking,  advantageous  to  the 
possessor.  And  it  is  just  at  the  period  of  life  when  the  first 
traces  of  senile  decay  begin,  that  the  embarrassment  caused 
by  an  excess  of  rotundity  is  most  apt  to  tell  upon  the  consti- 
tution. Generally  speaking,  a  moderate  accumulation  of  fat 
up  to  the  age  of  40,  or  even  45,  is  wholesome  rather  than 
otherwise ;  and  if  associated  with  a  broad  chest,  well-devel- 
oped and  active  muscles,  an  energetic  character,  and  a 
healthy  respiration  and  circulation,  will  tend  to  long  life, 
even  if  the  digestion  should  be,  as  often  happens,  rather 
feeble.  But  increase  of  fat  to  a  notable  degree  beyond  the 
middle  term  of  life  is  always  to  be  regarded  with  suspicion, 
as  implying  a  probability  of  vital  and  dynamic  conditions  of 
nutrition  tending  to  precipitate  tlie  process  of  the  senile  de- 
cay. And  anything  like  marked  obesity  persisting  to,  or 
increasing  at,  the  age  of  60  is  a  manifest  invasion  of  the 
prerogatives  of  that  age  which  has  been  characterized  as  tliat 
of  the  "  lean  and  slippered  pantaloon."  On  tl)e  whole,  it 
may  reasonably  be  doubted  whether  the  "spare"  constitution 
of  body,  if  it  be  free  from,  or  escape,  the  risks  incidental  to 
actual  disease  in  childhood  and  adolescence,  is  not  in  reality 
more  favorable  to  long  life  than  any  considerable  amount  of 
fat.     There  are  no  statistics  on  the  subject ;  but  the  medical 


PHTHISICAL    ATROPHY.  33 

observation  of  mankind  in  general  shows  that,  as  in  Pharaoh's 
dream,  it  often  happens  that  "the  ill-favored  and  lean-fleshed 
kine  did  eat  up  the  well-favored  and  fat  kine."  And  the 
spontaneous  and  instinctive  expression  of  the  late  Mr.  Bant- 
ing as  to  his  excessive  fatty  envelope,  viewing  it,  as  he  did, 
as  a  "  parasite"  destructive  both  to  health  and  comfort,  is 
not  so  far  removed  from  truth  as  are  many  popular  estimates 
of  this  condition  of  body. 

The  ideal  of  a  sound  and  perfectly  organized  bodily  struc- 
ture at  the  various  ages  of  life  has  been  so  beautifully  pre- 
sented to  us  in  the  masterpieces  of  ancient  and  modern 
sculpture,  that  every  medical  student  or  physician  who  de- 
sires to  keep  his  eye  and  mind  in  training  would  do  well  to 
spend  an  hour  now  and  then  in  a  gallery  of  casts  or  marbles, 
and  to  compare  the  perfect  forms  coming  from  the  chisel  of 
Phidias  or  Praxiteles,  Thorwaldsen  or  Ganova,  with  those 
habitually  seen  in  the  hospital  or  consulting-room.  He  will 
then  come  to  appreciate  by  his  senses  what  is  simply  a  phv- 
siological  and,  indeed,  a  pliysical  fact,  that  there  is  an  ideal 
relation  of  size  and  form  as  between  every  separate  part  of 
the  human  body;  and  that  every  outward  and  inward  struc- 
ture contributes  an  exactly-balanced  proportion  to  the  whole 
visible  result.  Tlie  study  of  this  proportion,  as  affected  by 
disease,  and  as  modified  by  action  and  suffering,  constitutes 
the  physiognomy  of  disease. 

In  spare  habits,  or  when  there  is  a  reasonable  suspicion,  d 
'priori,  of  phthisical  atrophy,  the  following  points  require 
to  be  observed,  especially  in  early  adult  life.  The  presence 
of  "clubbing"  of  the  finger  ends,  or  of  undue  curvature  of 
the  nails ;  the  red  line  on  the  gums,  said  to  be  more  or  less 
characteristic  of  tubercular  disease  ;  the  peculiar  momentary 
starting  and  elevation  of  the  skin  produced  by  a  tap  of  the 
finger  point  over  the  costal  cartilages,  and  described  as 
"  myoidema ;"  any  undue,  and  especially  any  unilateral, 
flattening  below  the  clavicles,  or  deformity  elsewhere  of  the 
chest,  and  any  inequality,  or  want  of  symmetry,  in  the  res- 
piratory movements  ;  any  rapid  and  too  easy  flushing  of  the 
face,  and  especially  that  limited  flush  of  the  cheek  with  pallid 
complexion  generally,  which  denotes  fever  in  an  exhausted 
constitution  ;  any  or  all  of  these  may  in  particular  cases  be 
valuable  indications  of  truly  morbid  emaciation.*    In  infants 

'  These  subjects  are  referred  to  in  detail  nnrler  the  sections  on 
the  Nails,  General  Signs  of  Pyrexia,  Gums   (Chapter  xi.),  and 


34  THE  rnTsroG.xoMY  or  disease. 

and  oliililren,  sometimes  also  in  adults,  it  is  not  uncommon 
to  observe  emaciated  limbs  and  face,  with  an  enlarged  abdo- 
men (almost  always  a  sign  of  grave,  often  tubercular,  disease). 
And  in  very  young  ijifants  the  presence  of  emaciation  gene- 
rally, with  a  retracted  abdomen,  and  a  large  head,  the  ante- 
I'ior  fontanelle  (if  still  open)  being  protruded  instead  of 
depressed,  is  a  combination  of  signs  of  the  gravest  import,  as 
tending  to  reveal  disease  of  the  meninges  of  the  brain,  even 
should  the  symptoms  otherwise  be  obscure  or  wanting ;  still 
more,  if  these  indications  are  accompanied  by  peculiarities  of 
expression,  or  abnormal  movements  of  the  eyes  (strabismus, 
nystagmus)  or  of  the  pupils ;  or  by  the  phenomenon  described 
by  Trousseau  as  the  "tache  cerebrale,"  and  considered  by 
him  to  denote  fever  with  a  cerel)ral  or  meningeal  lesion.' 

in  those  dealing  with  the  physical  examination  of  the  Chest 
(Chapter  xvi..  Part  1).  Myoidema  is  tlie  name  first  ajJijlied  by 
Dr.  Lawson  Tait  ('"Dublin  Journal  of  Medical  Science,"  vol.  52,  p. 
31())  to  a  phenomenon  observed  long  ago  by  Drs.  Graves  and  Stokes 
("Dublin  Hospital  Reports,"  vol.  5,  p.  70),  as  probably  charac- 
teristic in  some  degree  of  jjhthisical  emaciation,  and  as  being  found 
most  freqtiently  ' '  in  incipient  phthisis  over  the  seat  of  the  irrita- 
tion"— i.e.,  on  the  side  first  affected  and  in  the  supra-clavicular 
region.  According  to  Dr.  Tait,  the  sign  attends  especially  the 
so/'/e/iv'n^  stage  of  tubercle.  "After  each  stroke  of  the  ends  of  the 
fingers"  (say  the  first  discoveries  of  this  sign)  "  a  number  of  little 
tumors  aijpeared,  answering  exactly  to  the  number  and  situation  of 
the  points  of  the  fingers,  when  they  had  struck  the  integuments  of 
the  chest.  These  having  continued  visible  for  a  few  moments,  sub- 
sided, but  could  be  again  made  to  appear  on  rei^eating  the  percus- 
sion." [Mj'  observations,  in  very  nuraeroiis  instances,  lead  me  to 
concur  with  the  original  description  here  given  more  closely  than 
witli  the  details  of  fact  and  of  procedure  in  Dr.  Lawson  Tait's  paper. 
In  particular,  I  have  found  that  the  "little  tumors"  of  Drs.  Graves 
and  Stokes,  which  are  undoubtedly  the  more  important  part  of 
inyoidema,  are  produced  more  easily,  and  with  far  less  risk  of  fal- 
lacy, when  the  percussion  is  made,  not  over  a  voluntary  muscle  at 
all,  but  over  the  anterior  costal  cartilages.  The  name  therefore 
seems,  in  a  certain  sense,  a  misnomer,  if  it  is  intended  thereby  to 
snggest  that  the  contraction  of  the  fibrillse  of  voluntary  muscle  has 
anything  to  do  with  the  more  distinctive  phenomena.  The  "little 
tumors"  are  quite  evidently  due  to  a  temporary  contraction  of  mus- 
cular fibres  in  the  skin  itself,  similar  in  kind  to  those  of  the  dartos 
on  pinching  the  scrotum.  I  believe  the  phenomenon,  thus  iirter- 
l^reted,  to  have  some,  but  bv  no  means  a  pathognomonic,  signifi- 
cance.—W.  T.  G.] 

'  On  drawing  the  back  of  the  nail  or  the  blunt  end  of  a  pencil 
along  the  skin,  we  find,  in  the  healthy  subject,  that  a  momentary 
whiteness  of  the  part  is  followed  after  a  time  by  a  distinct  red 
streak.    But  in  certain  states  this  redness  is  much  more  easily  pro- 


ANEMIA.  -         35 

A  condition  frequently,  but  not  necessarily,  associated 
with  the  phthisical  or  morbidly  emaciated  habit,  is  Ancemia  ; 
a  tei'm  "which  has  been,  variously  defined,  but  which  may  be 
taken  as  corresponding  in  general  not  so  much  with  diminu- 
tion in  the  absolute  quantity  of  the  blood  as  with  deprecia- 
tion of  its  quality;  a  lower  specific  gravity  of  the  serum,  a 
more  or  less  considerable  fall  in  the  proportion  of  the  blood- 
corpuscles,  and  of  course  of  the  coloring  matter.  Physiog- 
nomically  considered,  antemia  is  recognized  chiefly  or  exclu- 
sively by  this  last  character  ;  and  the  most  marked  examples 
of  it  are  those  in  which  emaciation,  though  perhaps  present 
more  or  less,  is  not  extreme.  If,  indeed,  the  blood  is  simply 
reduced  in  quantity  as  a  part  of  the  general  emaciation,  but 
remains  not  greatly  out  of  proportion  to  the  other  tissues  (as 
in  many  cases  of  phthisical  emaciation),  the  characters  of 
antemia  will  not  be  at  all  strikingly  present.  The  lips  will 
remain  well  colored,  and  the  mucous  membranes  may  even 
be  morbidly  congested  in  such  a  condition.  But  when,  along 
with  only  a  moderate  reduction  in  the  amount  of  the  solid 
soft  tissues,  and  without  any  circumstance  tending  to  the  local 
determination  of  blood,  there  is  a  great  reduction  in  the 
quality  o'i  the  latter,  the  consequences  as  regards  the  appear- 
ance of  the  patient  are  very  striking.  There  is,  in  the  first 
place,  an  extremely  pallid  hue  of  the  whole  surface,  and 
especially  of  the  face ;  lips  not  quite  so  })ale  as  the  rest  of 
the  countenance,  but  entirely  devoid  of  their  natural  rosy 
hue  ;  the  conjunctivic  of  the  eyelids  similarly  })ale  ;  the  ocular 
conjunctiva;  bluish,  from  the  shining  through  of  the  choroid  : 
and  all  these  cliaracteristics  brought  out  the  more  remarkably 
in  dark  complexions,  inasmuch  as  the  tints  which  depend 
not  on  l)lood  but  on  pigment  may  be  unchanged.  Thus 
the  skin  may  be  nearly  as  pale  as  that  of  a  corpse,  and  yet 
there  may  be  dark  circles  (chloasma)  round  the  eyes  or  on 
the  brow  ;  or  the  natural  diffused  pigment  of  the  Avliole  sur- 
face may  be  so  exaggerated  as  to  give  to  certain  parts  of  it 
almost  the  appearance  of  the  skin  of  a  negro  or  mulatto  (the 
so-called  "bronzed  skin"  or  "Addison's  disease").  But 
in  cases  of  antemia,  pure  and  simple,  there  is  usually  no  special 
pigmentary  change,  and  the  whole  external  characteristics 

diTced,  and  is  likewise  very  much  more  intense  and  persistent ;  it 
is  to  this  excessive  redness  that  the  term  tache  cer^hrale  is  applied, 
from  its  being  frequently  ohserved  in  cases  of  acute  meningitis. 
But  it  is  now  quite  certain  that  it  may  he  found  equally  in  many 
cases  of  enteric  fever,  and  in  certain  other  diseased  conditions. 


36  THE    PHYSIOGNOMY    OF    DISEASE. 

suggest  merely  an  unduly  wtitery  or  much  impoverished 
blood.  The  skin  is  cool,  Jind  the  tongue  may  be  clean, 
though  extremely  pale ;  there  is  often  a  little  puffiness  of" 
the  eyelids  and  dropsical  swelling  of  the  ankles  ;  it  may  be 
(as  in  Bright's  disease)  even  general  dropsy  of  the  entire 
subcutaneous  tissues.  The  muscles  are  flabby  rather  than 
much  reduced  in  bulk ;  the  expression  is  that  of  great  lan- 
guor, but  not  of  suffering  or  of  anxiety  ;  if  the  texture  of 
the  skin  is  fine  and  delicate,  the  blue  veins  may  be  seen  be- 
low the  surface,  but  reduced  very  much  in  volume  as  com- 
pared with  the  normal ;  and  in  the  veins  of  the  neck  thei'e 
is  found  the  well-known  humming  of  the  "  ans^mic  murmur" 
or  "  bruit  de  diable."  A  special  variety  of  this  state  of  pure 
anaemia  is  chlorosis,  in  which  greatly  disordered  or  absolutely 
arrested  menstruatioti  in  young  girls  is  attended  by  all  the 
circumstances  above  noted,  often  with  a  very  remarkably 
green  tint  of  the  complexion  (as  the  name  implies).  In  all 
these  cases  the  blood,  tested  accurately  by  Malassez's  instru- 
ment or  by  the  ha^mochromometre,  shows  a  reduction  in  the 
amount  of  coloring  matter,  or  of  corpuscles,  equal  to  one- 
third,  one-half,  or  even  more  ;  and  in  this  way  a  physiog- 
nomic sign,  wliich  formerly  could  only  be  stated  in  general 
terms,  can  now  be  reduced  to  most  accurate  expression,  and 
made  subservient  to  exact  observation  as  to  the  progress  of 
disease  or  the  results  of  treatment.     (See  Chapter  ix.) 

When  this  anaemic  condition  is  recognized,  we  must  never 
rest  satisfied  in  the  investigation  of  the  case  till  we  have 
done  our  best  to  ascertain  the  probable  cause.  We  inquire 
for  the  history  of  any  hemorrhages  or  any  of  the  less  obvi- 
ous forms  of  loss  of  blood  described  elsewhere  (Chap,  ix.) 
A  similar  deterioration  may  result  from  the  chronic  influence 
of  the  malarial  fevers,  for  example,  or  from  the  recent  oc- 
currence of  some  acute  illness  from  which  the  patient's 
system  has  not  fully  recovered.  But  too  often  sucli  anaemia- 
is  only  symptomatic  of  the  serious  inroads  of  tubercular, 
syphilitic,  malignant,  or  renal  disease,  and  the  investigation 
of  the  urine  is  so  important  in  all  apparently  causeless  forms 
of  anfemia  that  it  must  never  be  neglected.  Present  or  past 
suppuration  of  a  chronic  character  may  likewise  be  respon- 
sible for  the  deterioration  of  the  blood  ;  the  extreme  pallor 
and  the  wax-like  appearance  of  patients  suffering  from  the 
lardaceous,  waxy,  or  amyloid  degeneration  of  the  viscera 
usually  arise  from  such  prolonged  suppurations,  but  this  dis- 
order may  also  be  due  to  less  obvious  causes.    The  examina- 


PLETHORA — COLLAPSE,  3T 

tion  of  the  blood  frequently  guides  to  the  diagnosis  of 
Leuka?mia  and  to  the  investigation  of  the  spleen  ;  or  the 
general  enlargement  of  the  lymphatic  glands  may  suggest 
the  presence  of  Hodgkin's  disease  as  the  cause  of  the  per- 
sistent anaemia.  But  after  eliminating  all  these  causes  of  the 
deterioration,  we  may  still  find  ourselves  in  the  presence  of 
a  simple  'progressive  pernicious  ancEmia,  the  origin  and 
pathology  of  which  still  remain  obscure,  while  the  tendency 
to  death  is  very  marked. 

The  converse  of  antemia,  in  medical  language  still  current, 
is  Plethora  ;  a  condition  which  has  had  a  great  deal  to  an- 
swer for  in  medical  pathology  and  treatment.  But  plethora, 
considered  merely  as  a  morbid  excess  of  blood,  can  hardly 
be  said  to  hold  its  place  among  recognized  pathological  states 
at  the  present  day;  fulness  of  blood,  in  other  words,  can 
scarcely  be  considered  morbid  unless  there  is  some  other 
pathological  change  either  as  regards  its  quality  or  its  dis- 
tribution. The  condition  to  which  the  name  plethoric  is 
usually  applied  is  one  in  whicli  there  is  stagnation  of  blood 
in  the  smaller  veins  of  the  surface,  giving  to  it,  especially  in 
the  face  and  nose,  the  rubicund  and  "port-winey"  appear- 
ance suggestive  of  the  days  when  two  bottles  of  that  luscious 
stimulant  were  regarded  as  a  moderate  allowance  for  a  gen- 
tleman at  an  after-dinner  sitting.  This  peculiarity  of  coun- 
tenance, as  well  as  the  plethoric  and  well-fed  condition 
generally,  when  occurring  in  persons  (especially  males)  past 
the  middle  term  of  life,  particularly  if  associated  with  hered- 
itary predisposition  or  with  known  habits  of  self-indulgence, 
has  been  regarded  as  among  the  notes  of  the  gouty  habit  or 
diathesis,  and  also,  along  with  a  short  and  thick  neck,  as 
among  the  predispositions  to  apoplexy. 

There  is  a  very  remarkable  condition  of  the  blood  and  of 
the  containing  vessels,  in  one  of  its  aspects  allied  to  antemia, 
in  another  to  plethora — that,  namely,  which,  attended  with 
coldness  of  the  surface  and  rapid  depression  of  the  powers  of 
life,  corresponds  with  the  so-called  "  collapse"  or  "  algide" 
stage  of  Asiatic  cholera.  In  so  far  as  this  condition  can  be 
here  dealt  with,  it  may  be  regarded  as  one  in  which  a  highly- 
concentrated  blood  encounters  resistance  in  being  driven 
through  the  capillaries ;  the  great  mass  of  the  blood,  there- 
fore, tending  to  accumulate  in  the  venous  system,  and  pro- 
ducing congestion,  and  even  ecchymosis,  by  rupture  of  the 
smaller  veins.  It  has  been  shown  by  chemical  analvsis  that 
4 


38  THE    PHYSIOGNOMY    OT    DISEASE. 

the  blood  in  this  comlition  has  lost  a  considerable  proportion 
of  its  water  and  albumen,  owing  to  the  enormously  rapid  and 
copious  discharges  from  the  intestinal  canal ;  but  the  blood 
corpuscles  remain,  for  the  most  part,  in  the  vessels.  There 
is,  therefore,  a  strange  combination  of  shrivelling  of  most  of 
the  textures  of  the  body  from  loss  of  fluid,  and  persistence  of 
blood-color,  altered,  however,  in  the  direction  of  lividity  by 
deficient  aeration.  A  person  in  this  state  has  the  skin,  espe- 
cially in  the  face  and  extremities,  of  quite  cadaverous  cold- 
ness, and  often  has  the  whole  attitude  and  expression  of  a 
corpse ;  the  ends  of  the  fingers  are  shrivelled,  the  features 
thin  and  pinched,  the  nose  and  all  the  extremities  livid  in  a 
high  degree;  the  conjunctivae  are  bloodshot  and  ecchymosed; 
the  eyes  sunk  in  the  orbits  ;  the  tongue  and  breath  cold;  the 
respiration  and  circulation  almost  inappreciable  ;  but  there 
is  no  disappearauce  of  the  external  fat,  nor  any  true  emacia- 
tion ;  the  breasts,  accordingly,  in  women,  and  the  abdomen 
in  corpulent  men,  remain  well  clothed  with  integument  even 
after  death.  A  condition  more  or  less  allied  to  this  is  seen 
in  some  cases  of  acute  peritonitis,  tending  rapidly  to  death, 
as  in  perforation  of  the  bowels,  which,  like  cholera,  may 
cause  death  by  collapse  in  a  few  hours,  though,  of  course, 
without  the  excessive  evacuations  above  referred  to. 

The  traditional  description  of  the  so-called  Fades  Hippo- 
cratica  is  not  very  far  removed  in  some  of  its  details  trom 
the  state  of  acute  collapse  as  above  described,  and  lias  been 
so  often  formulated  in  one  shape  or  other  by  compilers,  as 
conveying  the  elements  of  a  fatal  prognosis,  that  it  may  be 
as  well  to  transcribe  the  words  from  the  original  source  :  "a 
sharp  nose,  hollow  eyes,  collapsed  temples ;  the  ears  cold, 
contracted,  and  their  lobes  turned  out ;  the  skin  about  the 
forehead  rough,  distended,  and  parched ;  the  color  of  the 
whole  face  green,  black,  livid,  or  lead-colored."  But  the 
reader  will  do  well  to  consult  the  other  physiognomic  details 
in  Sec.  2—4  of  the  Prognostics  of  Hippocrates  (Dr.  Adams's 
translation,  vol.  i.  p.  236)  for  numerous  vivid  and  picturesque 
touches  which  are  now  among  the  common-places  of  medical 
observation.  And  the  description  of  the  phthisical  body  by 
Aretatus  is  equally  deserving  of  attention,  as  a  sample  of  ac- 
curate appreciation  of  detailed  facts  emanating  from  remote 
antiquity.  The  most  important  facts  of  the  description  re- 
ferred to  are  as  follows,  but  the  whole  chapter  in  the  excel- 
lent translation  of  Dr.  Adams  Avell  merits  perusal  : — 


CACHEXIA.  ~         39 

"  Voice  hoarse  ;  neck  slighly  bent,  tender,  not  flexible,  somewliat 
extended  ;  fingers  slender,  but  joints  thick  ;  of  the  bones  alone  the 
figure  remains,  for  the  fleshy  parts  are  wasted ;  the  nails  of  the 
fingers  crooked,  their  pulps  are  shrivelled  and  flat,  for,  owing  to 
the  loss  of  flesh  they  neither  retain  their  tension  nor  rotundity ;  and 
owing  to  the  same  cause,  the  nails  are  bent,  namely,  because  it  is 
the  compact  flesh  at  their  j^oints  which  is  intended  as  a  support  to 
them  ;  and  the  tension  thereof  is  like  that  of  tlie  solids.  Nose  sharp, 
slender  :  cheeks  prominent  and  red ;  eyes  hollow,  brilliant,  and 
glittering  ;  swollen,  pale,  or  livid  in  the  countenance  ;  the  slender 
parts  of  the  jaws  rest  on  the  teetli,  as  if  smiling  ;  otherwise  of  a 
cadaverous  aspect.  So  also  in  all  other  respects  ;  slender,  without 
flesh  ;  the  muscles  of  the  arms  imperceptible  ;  not  a  vestige  of  the 
mammje,  the  nipples  only  to  be  seen  ;  one  may  not  only  count  the 
ribs  themselves,  but  also  easily  trace  them  to  their  terminations  ; 
for  even  the  articulations  at  the  vertebrje  are  quite  visible  ;  and 
their  connections  with  the  sternum  are  also  manifest ;  the  inter- 
costal spaces  are  hollow  and  rhomboidal,  agreeably  to  the  configu- 
ration of  the  bone  ;  hypochondriac  region  lank  and  retracted  ;  the 
abdomen  and  flanks  contiguous  to  the  spine.  Joints  clearly  de- 
veloped, prominent,  devoid  of  flesh,  so  also  with  the  tibia,  ischium, 
and  humerus ;  the  spine  of  the  vertebrae,  formerly  hollow,  now 
protrudes,  the  muscles  on  either  side  being  wasted ;  the  whole 
shoulder-blades  ajiparent  like  the  wings  of  birds.  If  in  these  cases 
disoi-der  of  the  bowels  supervene,  they  are  in  a  hopeless  state. 
But,  if  a  favorable  change  take  place,  symjitoms  the  opposite  of 
those  fatal  ones  occur." — Aretreus,  Causes  and  Sjmpioms  of  Chronic 
Diseases,  Book  I.,  Chajjter  viii.,  On  Phthisis. 

In  association  with  the  various  atrophic  and  anemic  states 
above  referred  to,  we  have  to  consider  the  physiognomic  im- 
port of  another  much  abused  word,  around  which,  as  around 
the  words  "  diathesis"  and  "  temperament,"  a  great  deal  of 
very  obscure  patiiology  has  been  made  to  revolve.  Cachexia, 
in  its  original  and  etymological  sense  (xaxo;  and  iltj),  means 
any  bad  or  defective  habit  of  body — habitus  depravatus — 
usually  the  result,  not  the  cause,  of  disease.  The  term 
"  habit"  here  implies,  of  course,  chronicity ;  and  the  word 
cachexia  is,  accordingly,  one  consecrated  by  usage  to  the 
definition  of  states  characterized  by  chronic  lesions  of  nutri- 
tion, as  opposed  to  the  fevers  and  acute  diseases.  In  the 
systematic  nosologies — Cullen's  for  example — the  Cachexice 
form  an  order  including  all  clironic  diseases  of  nutrition  which 
are  not  strictly  local,  and  not  obviously  associated  with  fever. 
Hence  cancers,  dropsies,  rickety  affections  of  the  bones  in 
childhood,  and  above  all,  the  various  types  of  glandular, 
articular,  pulmonary,  cutaneous  diseases,  known  either  as 
scrofulous  or  tubercular,  are  commonly  enumerated  among 
the  cachexies ;  and  more  modern  authors  add  gout,  rheuma- 


40  THE    PHYSIOGNOMY    OF    DISEASE. 

tism,  scurvy,  and  sypliilis  to  the  list.  But  the  use  of  the 
thermometer  tends  very  much  to  break  down  the  distinctiou 
between  the  febrile  and  the  non-febrile  diseases — between 
the  pyrexicE.  and  cachexies;  and  in  some  of  the  latter,  e.  g., 
in  tubercular  diseases  and  in  syphilis,  the  febrile  element, 
though  spread  over  longer  periods  of  time,  and  tlierefore  less 
intense  as  a  rule,  is  quite  as  really,  if  not  invariably,  asso- 
ciated with  many  of  the  nutritive  changes  as  in  the  pyrexia; 
commonly  so  called.  It  cannot,  therefore,  be  admitted  that 
there  is  anything  in  the  essential  nature  of  a  cachexia  to  dif- 
ferentiate it  pathologically  from  a  fever,  or  from  an  acute 
disease  like  pneumonia.  There  is,  it  is  true,  the  element  of 
time,  implied  in  the  long  duration  and  very  gradual  evolu- 
tion of  the  disease  ;  but  the  relation  of  the  local  changes  to 
the  constitutional  disease  is,  in  the  cachexia  as  in  the  fever, 
a  matter  of  inference  from  the  study  of  the  whole  of  tlie 
phenomena ;  and  it  is  impossible  to  admit,  a  priori,  that  a 
specific,  and  latent,  constitutional  taint  always  precedes  and 
determines  the  local  aifection.  The  safe  rule  of  physiognomic 
diagnosis  here  is,  to  make  the  discovery  of  a  cachexia  (as  of 
a  diathesis)  an  inference  from  individual  facts  actually  ob- 
served and  verified  in  the  particular  case  ;  not  a  general 
formula  such  as  is  often  implied  under  the  terms  scrofulous, 
strumous,  syphilitic,  gouty,  or  cancerous  cachexia.  It  may 
be  easily  admitted,  indeed,  that  these  cachectic  states  actually 
exist  in  connection  with  the  diseases  named  ;  but  what  is  not 
so  easily  admitted  is  the  proof  of  the  cachexia  apart  from  all 
positive  manifestations  of  actual  disease  of  the  special  kind 
implied  in  its  name. 

The  following  brief  indications,  however,  may  be  noted  as 
regards  particular  types  of  cachexia.  In  the  Scrofulous  or 
strumous  variety,  as  also  in  a  certain  proportion  of  cases  of 
tuberculosis  in  the  adult,  there  may  be  found  evidences  of 
defective  nutrition,  or  emaciation,  extending  back  to  child- 
hood, and  modifying  the  entire  form  of  tlie  skeleton,  as  well 
as  tlie  integument.  A  slender  form,  and  a  narrow^  or  de- 
formed chest  may  be  accompanied  by  the  cicatrices  of  gland- 
ular abscesses,  or  of  sinuses  connected  with  the  bones ;  a 
delicate,  pale  skin,  or  one  marked  by  traces  of  eruptions  on 
the  scalp  or  elsewhere  ;  often  with  retarded  puberty,  and  im- 
perfectly developed  organs  of  sex  ;  flabby  muscles,  attenuated 
bones,  and  relatively  large  (sometimes  anchylosed  or  actively 
diseased)  joints.  The  upper  part  of  the  abdomen  may  be 
increased  in  bulk,  from  waxy  enlargement  of  the  liver  ;  or 


GOUT — DROPSY  -  41 

the  whole  iibdomen,  from  disease  of  the  peritoneum  or  mes- 
enteric glands.  The  patient  is  commonly  more  or  less  anas- 
mic,  and  is  often  (sometimes  periodically)  subject  to  febricula 
(hectic). 

In  the  Gouty  habit  there  is  frequently  no  cachexia,  pro- 
perly speaking,  at  all  appreciable  until  the  middle  term  of 
life  is  reached  or  past.  There  may,  on  the  contrary,  be  all 
the  indications  of  strong  vitality,  robust  conformation,  and 
great  bodily  and  mental  activity.  At  a  certain  period  of  life, 
however  (prematurely  or  not),  the  ordinary  signs  of  ageing 
occur ;  and  along  with  these  (and  with  the  cessation  of  the 
catamenia  in  women)  comes  an  increase  of  obesity,  or  the 
plethoric  development  of  the  facial  veins  (described  above)  ; 
eruptions  on  the  skin  ;  varicose  veins  in  the  lower  extremi- 
ties ;  manifestly  diminished  energy,  and  sometimes  oppression 
of  breatliing.  Preceding  or  succeeding  these  signs  may  occiu* 
the  special  deformities  due  to  the  local  deposits  of  uric  acid 
in  the  joints  of  the  toes  and  fingers,  or  (as  Dr.  Garrod  has 
remarked)  in  the  lobes  of  the  ears.  The  peripheral  arteries 
often  present  at  this  stage  well-marked  senile  degeneration. 
There  are,  however,  not  a  few  exceptions  to  these  remarks  ; 
and  the  gouty  habit  may  even  concur  with,  or  follow,  the 
scrofulous  cachexia,  as  age  advances. 

It  is  doubtful  whether  any  very  definite  cachexia  can  be 
said  to  accompany  Cancerous  disease,  apart  from  the  local 
developments  of  it  in  the  organs,  and  their  consequences. 
But  in  the  majority  of  cases  of  gastric,  hepatic,  omental,  or 
uterine  cancer,  and  in  not  a  few  mammary  and  other  exter- 
nal cancerous  growths,  there  are  either  extreme  emaciation 
and  antemia,  or  persistence  of  the  external  fat  with  flabby 
integuments,  and  a  peculiar  sallow  pale  complexion  ;  the 
expression  of  the  countenance  at  the  same  time  indicating 
habitual  suffering  and  great  despondency  of  mind. 

Drojjsical  cachexia  is  most  frequently  associated  with 
Bright's  disease  of  the  kidney.  It  is  marked  by  great  pallor, 
a  languid  expression  without  suffering,  unless  from  difficulty 
of  breathing  ;  often  puffiness  of  the  face  and  eyelids ;  absence 
of  fever,  and  an  almost  perfectly  dry,  cool  skin,  sometimes 
of  fine,  semi-transparent  texture,  at  other  times  locally  thick- 
ened and  even  wrinkled  or  furrowed  from  the  effects  of  long- 
continued  dropsical  effusions,  especially  in  the  lower  extrem- 
ities, scrotum,  and  loins. 

It  does  not  appear  at  all  clear  (notwithstanding  the  well- 
known  description  by  Dr.  Todd  of  the  "  rheumatic  diathesis"), 

4* 


42  THE    PHYSIOGNOMY    OF    DISEASE. 

that  either  in  acute  or  chronic  Rheumatism  there  is  any  de- 
finable cachexia  or  physiognomic  peculiarity  of  bodily  con- 
formation, apart  from  the  more  obvious  history  and  conse- 
quences of  the  disease. 

In  Rickets,  there  is  a  precursory  or  incubative  stage  of 
impaired  general  health  of  cachexia  (according  to  Sir  William 
Jenner,  Medical  Times  and  Gazette,  1860,  vol.  i.)  extend- 
ing usually  from  the  fourth  to  the  twelfth  month  of  the  infant's 
life.  More  or  less  emaciation  takes  place,  and  the  movements 
indicate  languor  and  peevishness  or  moroseness,  perhaps  with 
hot  skin  and  a  degi'ee  of  low  febrile  irritation.  By  and  by 
it  is  observed  that  the  natural  impulse  of  healthy  children 
to  pla}'  about,  does  not  exist  ;  the  child  prefers  to  lie  still, 
and  refuses  to  be  amused ;  the  superficial  veins  become  large, 
and  the  jugular  veins  especially  are  much  dilated  ;  the  hair 
continues  thin  upon  the  scalp,  and  the  fontanelle  remains 
widely  open.  Inter-current  diseases  of  the  chest  may  occur 
even  at  this  stage,  and  may  considerably  modify  the  progress 
of  the  rickety  cachexia ;  but  three  truly  physiognomic 
characters  are  specially  noted  by  Jenner,  as  appertaining  to, 
and  distinctive  of,  rickets,  even  in  advance  of  the  charac- 
teristic deformities  of  the  skeleton,  which  are  not  often  easily 
observed  until  the  little  patient  begins  to  walk.  The  first 
is,  profuse  perspiration  of  the  head  and  upper  part  of  the 
hod}',  especially  during  sleep,  with  large  and  full  veins  of  the 
scalp  and  sometimes  undue  pulsation  of  the  carotids.  The 
second  of  these  early  svmptoms  is  an  intolerance  of  covering 
at  night ;  the  child  insisting  on  kicking  the  bedclothes  off, 
and  lying  with  naked  limbs,  so  as  to  be  "  always  catching  cold," 
according  to  the  mother,  who  tries  in  vain  to  keep  the  infant 
properly  protected.  The  third  characteristic  symptom  is 
positive  suffering  when  touched,  or  even  when  approached, 
by  strangers,  obviously  from  general  tendei-ness,  both  of  the 
surface  and  of  the  muscles  and  bones  :  an  exaggeration  of  the 
state  above  described  as  existing  at  the  ver}"  earliest  stage  of 
this  cachexia.  "A  child  in  health,"  says  Sir  Wm.  Jenner, 
"delights  in  movements  of  every  kind.  It  joys  to  exercise 
every  muscle.  Strip  a  child  of  a  few  months  old,  and  see  how 
it  throws  its  limbs  in  every  direction  ;  it  will  raise  its  head 
from  the  place  where  it  lies,  coil  itself  round,  and  grasping 
a  i'oot  with  both  hands  thrust  it  into  its  mouth  as  far  as  pos- 
sible, as  though  the  great  object  of  its  existence  at  that  mo- 
ment was  to  turn  itself  inside  out.  The  child,  suflering 
severely  from  the  general  cachexia  which   precedes  and  ac- 


PHYSIOGNOMY    OF    FEVERS.  ~      43 

companies  the  progressive  stages  of  tlie  bone-disease  in 
rickets,  ceases  its  gambols  ;  it  lies  with  outstretched  limbs  as 
quietly  as  possible,  for  voluntary  movements  produce  pain." 
The  consequence  of  all  this  suffering,  after  a  short  period,  is 
further  permanently  imprinted  on  the  physiognomy  in  an 
aspect  not  only  of  languor,  but  of  premature  sadness  and  se- 
dateness,  as  of  age,  the  effect  of  which  is  increased  by  the 
inability  of  the  muscles  to  support  the  spinal  column,  Avhich 
becomes  curved  forwards  in  the  cervical  region,  and  back- 
wards in  the  dorsal.  The  bones  of  the  cranium  are  soft  and 
thin,  yielding  in  some  cases  to  pressure  like  card-board,  and 
the  form  of  the  skull  is  altered,  flattened  behind  or  at  the 
vertex,  and  protuberant  in  front.  There  is  enlargement  of 
the  ends  of  the  long  bones ;  the  ribs  are  '■■  very  soft,  so  that 
there  is  great  recession  of  each  rib  where  it  joins  the  costal 
cartilage  at  each  inspiration."  It  is  easy  to  see  in  this  de- 
scription of  the  signs  of  a  "  cachexia"  a  very  real  and  pre- 
sent disease,  the  source  of  all  the  deformities  and  permanent 
alterations  in  rickets,  to  which  we  have  already  alluded  as 
being  themselves,  in  after  life,  physiognomic  evidence  of  dis- 
turbed health  and  function  during  the  period  of  childhood. 

The  Syphilitic  cachexia  is  so  plainly  a  part  of  the  actual 
disease,  defined  and  demarcated  by  the  well-known  succes- 
sion of  the  various  stages  and  external  and  internal  lesions, 
that  it  seems  unnecessary  here  to  treat  of  it  in  detail,  as  the 
evidence  of  its  presence  is  dealt  with  under  special  sections 
in  connection  with  the  throat,  the  skin,  the  bones,  the  joints, 
etc.  But  in  long  standing  cases  of  syphilis  its  deep  influence 
on  the  system  is  often  manifested,  not  merely  by  an  appear- 
ance of  bad  health  and  general  delicacy,  but  also  by  a  dingy, 
sallow  and  somewhat  discolored  appearance  of  the  skin  of  t!.e 
face  ;  this  may  impart  to  such  patients  something  of  the 
physiognomic  aspect  of  malignant  disease  already  referred  to. 

In  all  bodily  conditions  involving  Fever,  whether  classed 
among  the  specific  fevers  or  not,  there  are  certain  physiog-. 
nomic  characteristics  which  ought  to  be  constantly  present 
to  the  mind  of  the  physician,  not  only  as  throwing  light  on 
the  diagnosis,  but  often  also  on  the  prognosis  and  treatment. 
Thus,  in  the  earliest  periods  there  is  the  somewhat  collapsed 
appearance,  the  pallor,  the  shivering,  and  cutis  anserina 
which  belong  to  the  cold  stage.  At  a  later,  but  still  early, 
period,  the  face  is  flushed,  the  expression  is  that  either  of 
languor  or  of  pain,  according  as  there  is  or  is  not  a  local  dis- 
ease ;  very  often  the  attitude  indicates  restlessness,  as  when  the 


44  THE    PHYSrOGNOMY    OP    DISEASE. 

patient  is  foiind  overnight  or  in  the  early  morning  with  tlie 
bedclothes  tossed  and  disordered,  and  the  body  more  or  less 
exposed.  In  this  stage  the  skin  may  be  dry  or  moist,  or  it 
may  be  dry  on  the  exposed  parts  and  moist  under  the  clothes, 
or  vice  versa}  In  certain  fevers,  as  in  the  rheumatic  and 
pya?raic  kinds,  moisture  of  surface  and  often  profuse  sweat- 
ing predominate  throughout ;  in  others,  as  in  scarlet  fever 
and  most  of  the  eruptive  fevers,  a  dry  hot  skin  is  more  char- 
acteristic of  the  early  stages  up  to  the  height  of  the  fever. 
In  phthisis  and  most  of  the  fevers  accom];anying  organic 
disease,  sweats  of  considerably  intensity  alternate  with  hot 
and  dry  skin,  often  repeatedly  in  the  course  of  twenty-ibur 
hours  (hectic  fever).  In  fevers  accompanying  diseases 
gravely  aifecting  the  respiration,  as  in  pneumonia  and  bron- 
cho-pneumonia, the  flush  on  the  cheeks  has  a  peculiar  duski- 
ness or  lividity  ;  this  is  very  notabl}^  the  case,  also,  in  acute 
tuberculosis.  In  some  cases  of  pyaemia  the  febrile  character- 
istics are  associated  with  a  yellowish  color  of  the  integument, 
or  even  with  jaundice.  A  like  change  may  take  place  when 
the  liver  is  directly  involved  in  the  disease,  and  even  in  some 
cases  of  pneumonia.  Fevers  de[)endiug  on  septic  poisoning 
of  the  blood  are  recognized  by  the  peculiar  odor,  as  of  putre- 
faction, which  exhales  from  the  body  even  at  an  early  stage, 
before  the  cadaveric  odor  or  the  symptoms  of  approaching 
death  have  appeared ;  such  cases  may  have  a  traumatic  ori- 
gin, or  they  may  occur  spontaneously,  as  in  some  instances 
of  enteric  fever,  of  erysipelas,  of  dysentery,  and  of  septic 
poisoning  from  infection.  Fevers  depending  on  abscess,  or 
upon  profuse  suppuration  in  connection  with  mucous  or 
serous  surfaces,  are  often  very  specially  characterized  by  the 
tendency  to  intense  and  repeated  shiverings,  which  can  be 
compared  only  to  the  commencing  stage  of  the  ague-fit.  A 
like  disposition  to  rigors  sometimes  follows  the  passing  of  a 
catheter  or  bougie  into  the  bladder,  and  this  without  any 
appreciable  injury  done  to  the  mucous  membrane.     All  these 

'  A  remarkable  contrast  to  these  irregularities  of  the  cutaneous 
transinration  in  fevers  is  to  be  found  in  most  cases  of  diabetes  mel- 
litus,  in  which,  with  great  emaciation  and  disorder  of  nutrition  and 
of  the  urinary  excretion,  the  surface  often  remains  throughout 
harshly  dry  and  cool,  the  natural  perspiration,  even  under  severe 
exertion,  heing  susj)ended.  Generally  sjjeaking,  a  dry  skin  which 
does  not  very  easily  perspire,  and  maintains  an  eciuable  temperature, 
is  tlie  sign  of  a  "  wiry''  frame  and  of  good  health.  Corpulent 
persons,  on  the  other  Laud,  perspire  easily. 


FATAL  PROGNOSIS  IN  FEVERS.       ^   45 

phenomena  may  be  fairly  included  in  the  range  of  physiog- 
nomic diagnosis  ;  the  more  precise  appreciation  of  tempera- 
tnre  througli  the  thermometer  will  come  under  consideration 
hereafter  (see  Cliapter  iii.).  In  all  fevers  which  continue 
for  more  than  a  brief  period,  the  tongue  becomes  more  or  less 
coated  with  a  white  or  yellow  fur ;  in  the  hectic  of  phthisis, 
however,  and  in  some  cases  of  enteric  fever  and  of  mild  inter- 
mittent, the  tongue  remains  surprisingly  clean  and  natural. 
As  the  fever  advances  the  fur  increases,  the  papilla?  enlarge 
and  become  congested,  the  dorsum  of  the  tongue  becomes 
dry,  usually  first  in  the  neighborhood  of  the  raphe.  At  a 
still  more  advanced  stage,  the  tongue  becomes  dry  all  over, 
brown,  and  roasted-looking,  while  incrustations  of  brown 
epithelial  debris  (sordes)  gather  upon  the  teeth,  alveoli,  and 
lips  ;  this  condition  is  specially  characteristic  of  typhus  and 
similar  fevers,  typhoid  pneumonia,  and  generally  speaking 
of  the  more  severe  continued  fevers  from  the  middle  of  the 
second  week  onwards ;  it  yields  very  gradually  after  the 
crisis,  the  fur  being  thrown  off  sometimes  in  patches,  some- 
times more  evenly,  and  the  natural  moisture  returning  (see 
also  Chap.  xi.).  At  the  stage  indicated  by  the  phenomena 
just  described,  there  has  usually  been  more  or  less  of  mental 
disturbance,  and  the  whole  attitude  and  manner  of  the  pa- 
tient, as  well  as  his  words,  indicate  a  wandering  mind  and 
semi-unconsciousness,  or  even  an  advance  into  coma,  with 
great  and  increasing  weakness ;  the  posture  being  in  the 
more  extreme  cases  absolutely  prostrate  on  the  back,  with 
the  mouth  more  or  less  open,  the  eyes  half  closed,  and  some- 
times a  film  of  dried  mucus  and  lachrymal  secretion  on  the 
conjunctive^  ;  the  pupils  being  often  contracted  so  as  to  re- 
semble pinholes,  and  insensible  to  light.  When  associated 
with  profuse  sweating,  or,  even  apart  from  this,  wdth  cold 
extremities  (the  febrile  heat  remaining  in  the  central  parts 
of  the  body),  the  prognosis  is  as  bad  as  it  well  can  be  in  any 
fever.  A  very  unfavorable  sign  is  a  starting  or  twitching 
movement  of  the  tendons  of  the  wrists  {subsidtus  tendinurn), 
and  tremor  of  the  muscles  generally  ;  still  more  unfavorable, 
if  possible,  are  the  movements  of  the  hands  described  by  Hip- 
pocrates, and  reproduced  by  countless  authorities  with  more 
or  less  conscious  imitation  for  more  than  2000  years  under 
the  names  of  carphologia,  fioccitatio,  etc. :  "  When  in  acute 
fevers,  pneumonia,  phrenitis  (acute  delirium),  or  headache, 
the  hands  are  waved  before  the  face,  hunting  through  empty 
space  as  if  gathering  bits  of  straw,  picking  the  nap  from  the 


46  THE  pnysioGxoMY  of  disease. 

coverlet,  or  tearing  cliaff"  from  the  wall — all  such  symptoms 
are  bad  ami  deadlv."'  The  peculiar  deadliuess  of  such 
symptoms,  it  may  be  remarked,  depends  upon  the  fact  of 
their  indicating  at  once  two  apparently  contrasted  states  of 
the  nervous  centres  and  especially  of  the  basal  ganglia  and 
niesencei)hale,  if  not  also  of  the  medulla  oblongats^ — viz., 
restlessness,  with  greatly  lowered,  if  not  lost,  sensibility  to 
external  impressions ;  unconsciousness,  with  disturbed  ex~ 
cito-motor  activity,  and  almost  always  witli  entire  absence 
of  real  sleep  {coma  vigil)  ;  the  movements  are  absolutely 
automatic,  and  yet  they  are  continuous,  being  excited  by  some 
purely  pliysical  irritation  of  the  motor  centres  apart  alto- 
gether from  consciousness,  and  acting  feebly  through  tlie 
efferent  nerves  upon  those  groups  of  muscles  especially  which, 
in  the  normal  condition,  exhibit  the  most  highly  differenti- 
ated and  exquisitely  combined  movements  under  the  influ- 
ence of  the  will.  To  the  same  order  of  phenomena  belong 
the  constant  mutterings  (typhomania  or  typhoid"-*  delirium), 
or  wordless,  and  sometimes  even  voiceless,  movements  of 
articulation  (mussitatio)  observed  in  the  later  stages  of  many 
severe  fevers,  conveying  to  the  mind  of  the  observer  merely 
the  idea  of  unrest,  witliout  the  faintest  suggestion  of  meaning 
or  even  of  consciousness.  (Compare  sections  on  Delirium 
and  Sleeplessness.) 

Tlie  specialties  of  physiognomic  diagnosis  bearing  on  dis- 
eases of  the  chest  will  be  discussed  hereafter.  (See  Dyspnoja, 
Orthopnoea,  etc..  Chapter  ix.). 

In  all  diseases  of  the  Nervous  si/stem  it  is  of  paramount 
importance  to  observe  the  attitude  and  bearing  of  the  patient, 

'  Prognostics,  IV.  ;  Adams's  translation,  vol.  i.,  p.  238. 

2  It  should  be  particularly  i-emarked,  as  necessary  for  the  recon- 
ciliation of  old  and  new  terms,  that  the  word  "  typhoid"  is  not  used 
here  in  the  special  and  limited  sense  given  to  it  by  Louis  and  the 
French  school  of  the  present  century,  as  a  designation  of  enteric 
fever,  but  in  that  larger  and  more  general  meaning  which  it  had 
from  at  least  the  time  ot  Galen,  of  typhus-like  (tZ^o^,  bI^o^).  Typhus 
and  most  of  its  derivatives,  including  typhomania,  are  Hippocratic 
words,  used  in  a  figurative  sense,  from  TZ<pog,  smoke,  as  indicating 
the  stupor  which  attends  the  graver  kinds  of  fever ;  and,  iu  the 
case  of  typhomania,  the  combination  of  stupor  with  restless  delirium 
— exactly  the  functional  contrast  referred  to  above.  The  etj^molo- 
gical  facts  are  interesting,  as  showing  how,  even  in  the  most  re- 
mote period  to  wliich  the  literature  of  medicine  extends,  clinical 
phenomena  which  only  receive  their  physiological  interpretation 
from  modern  science  were,  nevertheless,  sometimes  very  exactly 
noted. 


NERVOUS    DISEASES.  ^         4T 

his  manner  of  answering  questions,  of  putting  out  liis  tongue, 
speaking,  eating,  handling  familiar  objects,  walking,  etc. 
There  should  be  no  hurry  in  making  these  observations  ; 
sometimes  the  abnormal  facts  can  be  taken  in  at  a  glance,  as 
it  were ;  at  other  times  the  disease  may  elude  observation 
altogether,  until  brought  into  full  view  by  some  particular 
abnormal  act.  This  applies  in  a  very  special  sense  to  dis- 
orders supposed  to  be  of  the  mind,  which  have  often  a  very 
distinct  physiognomic  expression,  while  in  other  cases  they 
require  to  be  sought  out  through  tedious  processes  of  detail, 
amid  many  difficulties  and  possible  fallacies,  or  even  as 
underlying  positive  deception.  In  all  disorders  attended 
with  paralysis,  tremor,  or  convulsion,  there  will  be  at  some 
time  or  other  visible  phenomena  affecting  one  or  other  of  the 
modes  of  ordinary  activity  above  enumerated  ;  or  there  may 
be  deficient  power  of  evacuating  or  of  retaining  the  excre- 
tions of  the  bowels  and  bladder.  A  slight  tremor  of  the 
lips,  and  a  hesitating  utterance,  as  if  the  lips  and  tongue  had 
no  grip  (so  to  speak)  over  the  consonants,  will,  along  with  a 
peculiarity  in  the  gait,  an  unusual  stillness  in  the  muscles  of 
expression,  and  a  slight  disparity  of  the  pupils,  reveal  with 
almost  absolute  certainty  an  early  stage  of  one  of  the  most 
hopeless  of  diseases — general  paralysis  of  the  insane.  A  simi- 
lar but  more  complete  absence  of  facial  expression,  without 
any  of  the  other  characters  just  mentioned,  unless  it  be  a  flaw 
in  the  articulation  absolutely  limited  to  the  labial  consonants, 
will  give  the  key  to  a  more  rare,  but  far  less  dangerous  dis- 
order— double  or  bilateral  paralysis  of  the  portio  dura  :  while 
a  one-sided  action  of  the  face  and  brow,  with  a  permanently 
open  or  half-open  eye  on  the  side  of  the  paralysis,  and  a 
twist  of  the  mouth  towards  the  opposite  side,  will  show  forth 
tlie  much  more  common,  and  equally  isolated,  paralysis  of 
the  portio  dura  on  one  side  only.  An  open  mouth,  dribbling 
saliva,  an  awkwardly-moving  or  nearly  motionless  tongue, 
with  very  indistinct  articulation,  will  reveal  the  labio-glosso- 
laryngeal  paralysis  of  Trousseau  and  Duchenne.  The  trail- 
ing walk  of  the  hemiplegic  patient,  in  wliich  the  weight  of 
the  body  is  supported  on  one  limb,  while  the  other  (the 
paralyzed)  limb  is  either  dragged  on  the  gi-ound,  or  lifted  by 
a  movement  of  circumduction  proceeding  from  the  pelvis, 
and  favored  by  a  hitch  of  the  whole  body,  are  signs  which 
can  be  noted  at  once,  along  with  the  motionless,  sometimes 
rigid,  hand  and  arm  of  the  same  side,  semiflexed,  and  with 
the  fingers  bent  into  the  palm.     The  slow,  shuffling  gait  of 


48  THE    PHYSIOGNOMY    OF    DISEASE. 

the  true  paraplegic,  and  tlie  staggering,  erratic  progression 
of  locomotor  ataxy  ("as  if  his  legs  did  not  belong  to  him") 
are  equally  characteristic,  almost  at  first  sight,  and  easily 
distinguishable  from  the  limping  of  hip-joint  or  other  articu- 
lar disease,  and  from  the  reeling,  serpentine,  plainly  bewil- 
dered course  of  the  man  tending  homeward  after  a  clebauch, 
and  ready  at  any  time  to  lie  down  in  the  dirt,  to  save  the 
trouble  of  further  picking  his  way.  More  difficult  to  distin- 
guish from  the  latter  are  some  forms  of  apoplexy  or  of  cere- 
bellar disease,  of  the  diagnosis  of  which,  however,  it  is 
,  impossible  to  treat  in  this  chapter.  The  wrist-drop  of  lead 
]3aralysis,  the  irregular  manipulations  of  writer's  cramp  and 
other  peripheral  nervous  disorders  of  the  fingers,  must  also 
be  omitted  here,  though  essentially  of  the  nature  of  really 
physiognomic  diagnosis.  The  peculiar  jerkings  and  general 
"insanity  of  the  muscles"  which  characterize  chorea  must 
also  be  dismissed  with  a  reference  to  special  articles  and 
ti-eatises ;  as  also  the  Avhole  subject  of  tremor,  paralysis  agi- 
tans,  and  spinal  sclerosis.^ 

Keverting  to  the  disorders  which  seem  to  have  more  rela- 
tion to  the  mental  functions,  it  may  be  affirmed  witli  truth 
that  almost  every  distinct  type  of  insane  aberration  has  its 
peculiar  physiognomy,  from  the  extravagant  and  excited  ges- 
tures, shouts,  and  destructive  violence  of  the  maniac,  to  the 
muttering  and  moaning  of  the  victim  of  pure  melancholia, 
nursing  his  secret  sorrow  alone  ;  or  the  mindless,  speechless, 
sloueliing,  purely  animal  characteristics  of  the  extreme  de- 
mented patient,  puslied  about  almost  like  a  chattel  by  his 
keeper,  without  spontaneity,  and  only  capable  of  being  ex- 
cited into  a  temporary  sense  of  apparent  enjoyment  by  the 
sight  of  food,  or  of  tobacco,  or  perhaps,  in  some  instances,  by 
objects  of  sexual  desire.  And  witliin  these  divisions  lie  almost 
endless  varieties;  e.  ^.,  the  hysterical  maniac,  incoherent, 
extravagant  in  speech,  laughing  and  weeping  by  turns,  erotic 
and  shameless  in  her  behavior  at  times,  and  with  lucid  inter- 
vals, it  may  be,  of  long  duration  ;  the  harmless  and  good- 
humored,  half-demented  creature,  pleased  with  every  slight 
attention,  easily  amused,  and  always  busy  with  some  me- 
chanical   or    artistic  occupation — knitting,   or    drawing,  or 

'  These  subjects  are  discussed  in  special  sections  of  Chapters  v., 
vi.,  and  viii.  Consult  the  index  for  the  names  of  the  various  dis- 
eases and  symptoms  referred  to.  See  also  in  particiilar  the  sections 
on  Si)cech,  Walking  and  Balancing,  T\vitchings,  etc. 


INSANITY — IDIOCY.  ~       49 

writing  long  snatches  of  nonsense  in  verse,  or  playing  the 
fiddle  ;  the  suspicious  monomaniac,  who  follows  you  with  his 
eye  at  every  turn,  grumbles  and  mutters  audibly  his  suspi- 
cions, and  would  no  doubt  at  times  lay  violent  hands  on  you 
if  permitted ;  the  egotist,  who  adopts  the  manner  and  style 
of  the  Emperor  of  India,  or  the  Queen  of  Sheba,  or  of  more 
sacred  characters  than  these,  or,  it  may  be,  of  the  Creator  of 
the  Universe !  Each  of  these  insanities  tends  to  produce,  as 
it  were,  a  physiognomy  for  itself;  the  whole  physical  habit 
becomes  so  moulded  upon  the  prevalent  delusion,  that  it  may 
almost  be  said  that  a  glance  at  the  patient  and  his  surround-, 
ings  gives  some  considerable  insight  into  the  special  character 
of  his  mental  unsoundness.  Still  more  curious,  because  more 
inexplicable,  are  the  physiognomical  individualities  that  lie 
within  the  apparently  narrow  bounds  of  idiocy  and  imbecility. 
There  is  the  congenital  idiot,  often  dwarfish  in  body  and 
infantile  in  expression  and  habits,  sexually  undeveloped,  with 
a  ^-shaped  palate,  and  one  or  more  apparently  accidental 
bodily  deformities,  living  the  life  almost  of  an  infant :  the 
ci-etin  of  the  Alpine  valleys,  goitrous  and  otherwise  physically 
deformed ;  the  epileptic  idiot ;  the  hydrocephalic  idiot ;  the 
microcephalic  idiot ;  the  paralytic  idiot.  Of  all  these,  and 
of  other  varieties,  the  physical  and  physiognomic  characters 
have  been  admirably  described  by  Dr.  Ireland  in  a  classic 
work  recently  published.  (For  further  details  see  also  Chap- 
ter viii.  on  Insanity.) 

As  in  the  insane  and  the  imbecile  physiognomic  diagnosis 
assumes  a  special  importance,  from  their  inability,  in  many 
instances,  to  give  a  coherent  account  of  themselves,  so  it  may 
be  said  that  in  infancy  and  in  early  childhood  the  physiog- 
nomy of  disease  constitutes  by  far  the  most  important  aspect 
of  diagnosis  considered  as  a  whole,  unless  in  the  case  of 
positive  physical  signs  directly  bearing  on  the  state  of  the 
internal  organs.  If  an  healthy  infant  of  from  four  to  six 
months  is  carefully  studied  from  the  medical  and  physiolog- 
ical point  of  view,  it  will  be  found,  of  course,  to  have 
increased  considerably  both  in  stature  and  weight  since  its 
birth  ;^  but  in  addition  to  the  mere  growth  and  increase  of 
bulk  a  skilled  eye  and  touch  will  easily  determine  the  fact 

'  According  to  Quetelet,  an  infant  grows  in  length,  nearly  seven 
inches  and  a  half  during  the  first  year  of  life  ;  in  the  second  year, 
only  half  of  this  amount ;  and  in  the  third  year,  only  one-third  of 
it.  From  the  fourth  or  fifth  year  of  life  the  increase  is  a  little  over 
two  inches  (56  millimetres)  annually  till  the  age  of  puberty. 
5 


50  THE    PHYSIOGNOMY    OP    DISEASE. 

that  the  muscular  structure  of  the  limbs  have  acquired  much 
greater  firmness,  plumpness  of  outline,  and  with  these  more 
apparent  spontaneity  and  definiteness,  so  to  speak,  of  phy- 
siological activity.  The  cause  of  this  change  is  partly  the 
constant  exercise  of  the  muscles  themselves,  and  partly  the 
rapid  development  of  the  nervous  centres  presiding  over  the 
muscular  movements.  As  yet,  the  movements  are  mostly 
automatic;  there  are  few,  if  any,  pur[)ose-like  acts  of  pre- 
hension -with  the  hands,  for  instance,  until  nearly  six  months 
old,  although  an  object  conveyed  into  the  grasp  is  held,  just 
as  the  nipple  is  held  when  placed  between  the  lips.  There 
is,  how^ever,  a  constant  activity  of  the  limbs,  both  upper  and 
lower;  and  a  gradual  education  of  all  the  voluntary  muscles, 
including  those  of  expression  and  voice,  to  the  functions 
afterwards  to  be  performed  under  the  influence  of  the  intelli- 
gent will.  The  child  is  obviously  a  sentient  and  emotional 
being,  and  one  of  the  half-conscious  impulses  which  guide  its 
movements  when  awake  is  the  positive  delight  which  it 
experiences  in  giving  to  every  individual  voluntary  muscle, 
down  even  to  the  smallest  of  those  which  move  the  toes  and 
fingei'S,  a  fair  share  of  daily  and  hourly  exercise.  "Watch  an 
infant  four,  or  six,  or  eight  months  old,  crowdng  Avith  the 
mere  physical  enjoyment  of  perpetual  motion,  kicking  its 
arms  and  legs  about  as  it  is  removed  from  its  bath  and  lies 
naked  in  its  nurse's  arms,  and  you  will  be  compelled  to 
recognize  the  force  of  this  healthy,  but  apparently,  as  yet, 
unintelligent  instinct.  It  is  the  same  instinct  as,  in  the  more 
developed  system  of  the  kitten  at  a  like  or  yet  earlier  age, 
leads  it  to  chase  its  own  tail,  and  to  do  a  thousand  pranks 
that  seem  aimless,  but  are  in  fact  surely  guided  towards  a 
definite  end  in  the  evolution  both  of  the  bodily  and  the 
mental  faculties — viz.,  the  instinct  of  Play}  Next  to  the 
yet  more  absolutely  necessary,  and  therefore  earlier  dis[)layed, 
instinct  of  suction,  this  is  the  faculty  that,  more  and  earlier 
than  any  other,  rules  the  life  and  determines  the  physiog- 
nomy of  the  infant.  We  have  seen,  in  the  graphic  words  of 
Sir  William  Jenner,  how  this  power  of  spontaneous  and 
Avholesome  bodily  movement  is  disturbed  in  the  ricketty 
cachexia.     It  might  be  added  that  in  almost  every  serious 

'  Dr.  John  Strachan  has  discussed  the  physiological  and  educa- 
tional aspects  of  tliis  subject  in  an  admirable  little  treatise — "What 
is  Play  ?"  Edinburgh,  1877  ;  a  work  which  may  be  recommended 
to  the  perusal  of  every  student  and  practitioner  of  medicine. 


INFANTILE    DISORDERS.  "      51 

disease  of  early  infancy  and  childhood  it  is  possible,  by 
studying  carefully  the  relation  of  the  spontaneous  movements 
to  each  other,  and  to  the  attitude  and  expression  of  the  child, 
its  cries,  smiles,  inarticulate  noises,  its  color,  state  of  general 
nutrition,  behavior  in  sleep  and  in  waking,  to  arrive  at  a 
seasonable,  and  often  a  perfectly  just,  conclusion,  as  to  the 
general  nature  and  locality  of  the  disease.  If  there  is  paral- 
ysis in  any  limb;  if  the  spine  or  any  individual  joint  is  weak 
or  pained  ;  if  the  breathing  is  obstructed ;  if  the  abdomen  is 
pained  and  tender,  or  distended  ;  if  the  bony  skeleton  is  too 
yielding,  and  does  not  afford  the  requisite  support,  or  affords 
it  only  with  pain ;  in  each  case  there  is  a  typical  departure 
from  the  normal  attitudes  and  modes  of  activity,  as  displayed 
in  the  waking  moments  ;  or  from  the  happy,  quiet  sleeping 
existence  of  the  healthy  infant.  Of  course  it  is  absolutely 
necessary  that  the  survey  should  be,  as  far  as  possible,  com- 
plete and  deliberate ;  do  not,  therefore,  confine  the  observa- 
tion to  the  face,  or  be  satisfied  with  feeling  the  pulse,  and 
looking  at  a  bundle  of  clothes.  Note  the  color  of.  the  cheeks, 
the  heat  of  the  skin  all  over  the  body,  the  presence  (especially 
in  sleep)  of  twitchings,  startings,  sudden  catchings  of  the 
breath,  or  breathing  with  effort  and  with  imperfect  expan- 
sion of  the  chest ;  observe  the  descent  of  the  diaphragm,  the 
elevation  of  the  ribs  on  both  sides,  the  state  of  the  abdominal 
wall  and  its  contents,  the  state  of  the  fontanelle,  the  size  of 
the  head  as  compared  with  the  body,  and  any  abnormal  flat- 
tening of  the  vertex  or  j^rojection  of  either  frontal  region  ; 
the  fulness  of  the  veins  of  the  head  and  neck,  the  presence 
or  absence  of  local,  or  undue,  perspirations ;  observe  if  the 
eyes  are  completely  closed,  as  in  healthy  sleep,  or  half-closed 
as  in  some  febrile  and  cerebral  diseases  ;  if  the  child  buries 
its  head  in  the  pillow,  or  has  the  hair  worn  away,  as  it  were, 
on  some  parts  of  the  head,  or  has  the  neck  twisted  backwards, 
and  stiff;  or,  at  a  more  advanced  age,  if  he  grinds  the  teeth, 
or  picks  the  nose  habitually ;  if  the  nostrils  are  dilated  in 
inspiration,  and  if  there  is  any  noise  in  the  larynx,  or  in  the 
chest ;  if  the  surface  shows  any  eruptions,  or  the  mouth  and 
anus  any  mucous  patches  or  condylomata,  or  other  evidence 
of  syphilitic  disease  ;  if  the  muscles  are  flabby  or  well-nour- 
ished ;  if  the  abdomen  is  retracted,  or  tumid  and  resistant, 
or  soft,  natural,  and  easily  manipulated.  All  or  most  of 
these  observations  can  be  made  even  in  a  sleeping  child  with- 
out disturbing  it  too  much  ;  but  of  course  it  will  be  best  to 
take  them  in  the  order  most  convenient  for  this  end.     The 


52  THE    PHYSIOGNOMY    OF    DISEASE. 

pulse  and  i-espiration  should  also  be  numbered,  if  possible, 
during  sleep.  Other  observations,  as  on  the  mouth,  jxums, 
teeth,  tongue,  throat,  nosti-ils,  ears,  as  also  all  detailed  phy- 
sical explorations,  should  be  postponed  until  all  the  informa- 
tion that  can  be  procured  during  sleep  and  waking  from  these 
physiognomic  data  has  been  carefully  gathered  and  noted, 
and  until  some  cpiestions  as  to  previous  history  have  been 
put. 

Most  of  the  inferences  to  be  drawn  from  the  preceding 
observations  will  be  commented  on  in  other  parts  of  this 
book.  We  may  here,  ther'^'bre,  fitly  close  our  chapter  on 
the  physiognomy  of  disease.' 

'  For  consultation,  by  those  who  may  wish  to  follow  out  the  medi- 
cal literature  of  this  subject,  the  following  authorities  may  be  re- 
ferred to,  with  a  caution,  however,  in  the  case  of  some  of  them, 
sufficiently  indicated  in  the  opening  paragraphs  of  this  chapter  : 
Galen  on  the  Temperaments,  especially  in  his  treatise  "  De  Tempe- 
ramentis  (ttspI  xpit^mot),  and  elsewhere  in  many  places,  for  which 
see  the  general  index,  Kiihn's  edition,  vol.  xx.,  p.  588.  For  a  more 
brief  resume,  see  Panltis  ^gineta,  translated  by  Adams,  vol.  i. 
pp.  84-86  ;  Lavater,  "  L'Art  de  Connaitre  les  Hommes  par  la  Phy- 
sionomie,"  Paris,  1806—7;  Banmgaertner,  "  Physiognomice  Patho- 
logica,"  with  Atlas  in  folio,  1839  ;  Sir  Charles  Bell,  "  Essays  on  the 
Anatomy  and  Philosophy  of  Expression,"  London,  1824,  6tli  edit. 
1872;  Laycock,  Lectures  in  "Med.  Times  and  Gazette,"  1862,  vol. 
i. ;  Corfe,  "  Med.  Times  and  Gazette,"  1867,  vol.  i. ;  Charles  Dar- 
win, "  The  Expression  of  the  Emotions  in  Man  and  Animals,"  1872, 
and  later  editions — a  work  full  of  original  suggestion  and  philoso- 
phical research,  though  not  specially  occupied  with  disease,  or  with 
its  physiognomic  expression. 


53 


CHAPTER  II. 

EXAMINATION  AND  REPORTING  OF  MEDICAL 

CASES. 

CASE  TAKING. 

In  examining  cases  brought  under  his  notice  a  physician 
is  guided  by  the  circumstances  in  which  he  finds  the  patient, 
and  by  his  knowledge  and  experience  of  tlie  condition  with 
■whicli  lie  has  to  deal,  and  so  one  case  is  approached  in  one 
way,  and  another  in  quite  a  different  manner.  No  one 
method  can  actually  be  applied  to  all  cases  ;  indeed  no  one 
method  could  possibly  be  the  best  if  used  indiscriminately. 
When  a  patient  is  gasping  for  breath  and  scarcely  able  to 
speak,  we  must  reserve  our  questions  for  the  most  important 
points.  When  a  patient  is  delirious,  muddled,  or  obviously 
unreliable,  it  is  vain  to  try  to  procure  from  him  a  connected 
statement  of  his  history  and  his  sensations.  If  actually  in- 
sensible, or  in  a  fit,  we  dare  not  delay  our  examination  of  his 
condition,  so  far  as  this  can  be  ascertained,  simply  because 
we  would  prefer  to  await  the  arrival  of  information  as  to  the 
previous  history  or  the  mode  of  attack ;  such  delay  (apart 
from  all  ])ractical  questions  of  treatment)  might  deprive  us 
of  the  only  opportunity  of  ascertaining  the  nature  of  the 
ailment.  Nor  would  a  physician  explore  the  family  history 
of  a  person  with  scabies  in  the  same  way  in  which  he  would 
investigate  this  part  of  a  phthisical  case ;  his  question  directed 
to  the  patient  with  scabies  on  this  matter  would  probably  be 
limited  to  a  few  pointed  inquiries  to  ascertain  the  infectious 
character  of  the  eruption,  from  its  presence  in  other  members 
of  the  family.  Usually  we  begin  by  inquiring  more  or  less 
fully  what  the  patient  feels  to  be  wrong  ;  this  serves  to  direct 
the  first  part  of  our  physical  exploration  of  the  organs,  and 
the  mischief  detected  there  often  sends  us  back  to  inquire 
into  the  exact  way  in  which  the  illness  began,  the  previous 
health,  and  the  family  history ;  certain  points  thus  ascer- 
tained may  demand  a  renewed  examination  of  the  organs, 
or  the  exploration  of  other  parts. 

5* 


54  EXAMISATIOX    OF    MEDICAL    CASES. 

In  urgent  ceases  we  seize  upon  the  severest  sjmittoms,  the 
dyspnoea  or  jjiain  for  example,  and  try  to  get  the  greatest  in- 
formation attainable  at  the  least  cost  to  the  patient,  sparing 
him  as  much  as  f>05sible  the  fatigue  of  questioning  or  of  phy- 
gical  examination,  according  as  the  one  or  the  other  causes 
the  greatest  annoyance  or  danger,  filling  up  the  gaps  from 
th<'  information  supplied  by  the  attendants. 

When  there  are  obvious  features  of  capital  importance,  such 
as  jaundice,  febrile  eruptions,  bron2nng  of  the  skin,  pulsating 
tumor  in  the  neck,  serious  hemorrhages,  profound  anaemia. 
and  the  like,  we  often  begin  with  these  facts,  and  having  as- 
certained their  origin,  proceed  in  our  inquiries  to  the  other 
fiarts  of  the  case  and  its  earlier  history. 

When  the  iUness  is  obscure,  a  more  systematic  examina- 
tion of  all  the  organs  and  functions  of  the  body,  and  an 
equally  careful  inquiry'  into  the  historv'  of  the  patient  and  his 
family,  may  be  required  to  unravel  the  difficulties. 

In  reporting  cases,  likewise,  verv'  diiferent  methods  are 
pursued  by  the  same  yjhysician,  according  to  the  varying 
peculiarities  and  the  different  points  of  interest  and  import- 
ance in  each  case,  and  also  according  to  the  object  he  has  in 
view  in  making  the  record. 

The  student  in  the  medical  wards,  however,  is  not  placed 
in  exactly  the  same  position.  The  cases  assigned  to  him  for 
reporting  are  usually  selected  by  those  in  charge  of  the  pa- 
tients, and  they  seldom  fail  to  warn  the  student  when  pro- 
longed pliy.sical  examinations  would  be  dangerous,  or  when 
special  parts  of  tlie  investigation  must  be  omitted  or  passed 
over  slightly.  To  the  student,  therefore,  a  more  uniform 
plan  can  be  recommended,  and  it  is  the  more  useful  to  him, 
as  without  some  method  to  guide  him  he  is  apt  to  omit  notic- 
ing various  important  features  of  the  ailment.  This  may 
arise  from  forgetfulness,  and  from  there  being  so  many  points 
which  have  to  be  investigated ;  but  the  student  is  likewise 
apt  to  omit  important  parts  of  the  inquiry'  from  supposing 
that  the  indications  of  disease  found  by  him  in  one  part  are 
sufficient  to  account  for  the  whole  illness;  having  found,  for 
example,  the  presence  of  albumen  in  the  urine  and  other 
evidence  of  renal  disease,  the  beginner  may  never  think  of 
examining  the  heart,  and  may  set  down  a  distinct  loss  of 
vision  to  some  accidental  coincidence. 

It  is  in  the  examination  of  the  actual  state  of  tlie  patient 
(status  pra-sens)  tliat  the  student  chiefly  requires  the  assist- 
ance  of  some   method    in    liis   investigation    of  the    various 


CASE    TAKING.  .       55 

symptoms  and  physical  signs.  The  following  plan  is  recom- 
mended hy  Professor  Sanders,  Avho  has  devoted  much  con- 
sideration to  this  subject.  A  division  into  "  Anatomical 
Regions"  and  "  Pliysiological  Systems"  is  first  made,  as  it 
assists  in  reviewing  the  signs  and  s^Tujjtoms  of  disease;  by 
dealing  with  these  regions  and  systems  methodically  we  can 
detail  the  "  signs"  and  the  "'  symptoms"  separately,  under 
each  system  ;  we  thus  save  allied  facts  from  being  divorced 
from  each  other,  and  yet  prevent  the  confusion  which  is  apt 
to  arise  from  mixing  up  diverse  symptoms  and  signs  togetlier. 
The  "  Regions,"  also,  can  be  combined  with  the  "  Systems," 
by  classifying  the  systems  under  the  regions  according  to  the 
situation  of  their  principal  organs. 

A  preliminary  division  which  is  found  convenient  is  to 
separate  the  "Exterxal"  from  the  •'  Ixterxal."  Under 
the  External  portion  may  be  included  tiiose  obvious  features 
which  go  to  form  the  "  physiognomy  of  disease,"  or  refer  to 
the  peculiarities  of  the  patient.  The  temperature  of  the 
body,  although  really  an  internal  plienomenon,  is  usually 
judged  of  by  the  feeling  of  the  skin,  or  by  the  application  of 
a  thermometer  to  the  axilla ;  it  is  thus  included  under  this 
department.  The  conformation,  weight  and  muscular  devel- 
opment, the  apparent  age  as  compared  with  the  real  age,  the 
expression  and  complexion  of  the  face,  the  presence  of  dropsy, 
the  posture,  and  the  like,  come  in  here.  An  examination  of 
the  skin  for  eruptions  of  any  kind,  and  a  survey  of  the  limbs 
and  joints,  for  any  signs  of  disease,  likewise  fall  to  this  por- 
tion of  the  investigation.  Such  facts  as  glandular  enlarge- 
ments may  either  be  stated  in  this  connection,  or  in  a  more 
detailed  manner  in  connection  with  the  regions  where  they 
are  noticed  ;  the  extent  of  these  affections  usually  determines 
our  choice  in  such  cases. 

The  Internal  examination  may  be  subdivided  into  the 
"  Regions"  of  the  Head,  Thorax,  and  Abdomen.  The 
Head  includes  the  great  organ  of  the  "  Nervous  System," 
and  as  the  spinal  and  peripheral  nervous  system  cannot  well 
be  separated  from  the  cerebral,  in  any  preliminary  examina- 
tion, we  include  all  parts  of  the  nervous  systems  in  this  re- 
gional division.  The  Thorax  contains  the  great  central 
organs  of  the  "  Respiratory"  and  "  Circulatory"  systems, 
and  as  these  cannot  be  duly  examined  without  considering 
the  peripheral  portions,  they  also  are  dealt  with  all  together 
under  this  region.  The  Abdomen,  likewise,  as  a  region, 
supplies    us   with    two   systems — the    "Digestive"    and    the 


56  EXAMINATION    OF    MEDICAL    CASES. 

"  Genito-urinaiy" — for  a  complete  exploration  in  their  Avhole 
extent. 

It  is  supposed  to  be  an  advantage  to  begin  always  with  the 
External  part  of  the  examination,  as  some  points  of  it  are 
otherwise  apt  to  be  overlooked  ;  it  can  usually  be  rapidly  dis- 
missed unless,  indeed,  it  constitutes  the  principal  part  of  the 
case.  In  the  Internal  regions  Professor  Sanders  recom- 
mends us  to  deal  with  the  systems  whose  great  organs  are 
contained  in  the  same  cavity  before  proceeding  to  the  others; 
to  discuss  the  heart  and  lungs  in  sequence,  for  example,  be- 
fore proceeding  to  the  digestive  and  genito-urinary  systems 
and  their  organs  contained  in  the  abdomen. 

We  begin  with  the  system  which  seems  from  the  history 
or  from  the  general  aspect  of  the  case  to  be  one  most  essen- 
tially affected,  and  we  also,  of  course,  consider  it  in  much 
fuller  detail.  Hospital  cases  are  usually  so  far  prepared  for 
the  student  by  the  previous  record  of  the  temperature  and 
the  preservation  of  the  urine  and  expectoration  for  his  in- 
spection. 

"  If  we  find  orthopnoea,  general  anascarca,  and  distended 
jugular  veins,  we  begin  with  the  circulatory  system. 

"  If  we  find  purulent  expectoration,  emaciation,  and 
clubbed  finger  ends,  we  begin  with  the  respiratory  system. 

"If  we  find  albuminous  urine  and  pale  putfy  countenance, 
we  begin  with  the  urinary  system. 

"If  we  find  jaundice  and  protuberant  abdomen,  we  begin 
with  the  digestive  system. 

"If  we  find  paralysis  or  convulsive  twitches,  we  begin 
with  the  nervous  system,  and  so  forth."  (Dr.  William  Rob- 
erts.) 

These  anatomical  and  physiological  divisions  could  never, 
however,  preserve  us  from  making  serious  omissions  in  our 
reports,  unless  each  detail  in  each  system  were  investigated 
with  an  absurd  and,  indeed,  a  reprehensible  completeness. 
The  manifestations  of  disorder  in  the  various  systems  often 
appear  in  the  most  unexpected  quarters.  These  points  can 
only  be  learned  by  a  varied  experience  of  morbid  conditions, 
such  as  the  beginner  cannot  be  expected  to  possess.  The 
detailed  description  of  the  symptoms  dealt  with  in  the  sequel 
may  supply,  to  some  extent,  from  the  experience  of  others, 
the  want  thus  felt  by  a  beginner,  so  that  when  he  comes 
upon  any  of  these  symptoms  he  may  know  how  to  pursue 
the  investigation  in  its  various  ramifications,  and  to  estimate 
to  some  extent  the  bearinor  of  the  facts  on  the  diasrnosis. 


DISEASE  — RESULT.  ~      57 

As  an  indication  of  the  points  to  be  investigated  under 
each  heading,  and  the  order  in  which  the  inquiry  may  be 
taken  up,  the  following  tabular  statement  is  appended.  It 
is  used  by  Dr.  Sanders  in  his  clinique  at  the  Edinburgh 
University : — 

DISEASE.     RESULT. 

Peelimixariee — 1.    Name.     ^g^.     Occupation.     Residence.     Date 
of  admission.     No.  of  Bed  and  Ward. 

2.  Complaints,  as  stated  by  patient,  or  reported  bj  friends  ;  or 

obvious  morbid  conditions,  e.  </.,  Jaundice. 

3.  History  of  present  attack;  of  previous  health.     Family  his- 

tory.    Social  history. 

Present  Condition — 

Regions  A,  Ej-ternal. — 1.  General  condition  as  to  development, 
height,  weight,  muscularity,  posture.  2  Expression  of 
face.  3.  Integument;  temperature,  j)erspiration,  erup- 
tions, tumors,  «Sic.     4.  Condition  of  limbs  and  joints. 

Regions  B,  Internal. 

Commence  with  the  region  and  system  affected,  and  describe 
all  the  systems  of  a  region  before  going  to  another. 

Head,  Nervous  System: — 

Peripheral — Nerves;  motion,  sensation,  special  senses. 
Central — Brain  and  spinal  cord ;  intelligence,   sleep,  head- 
ache, &c. 

Thorax,  Respiratory  Systeji — 

Peripheral — Nose ;  action  of  alse  nasi.     Larynx  ;  voice  (laryn- 
goscope).    Trachea.     Cough. 

Central — Lungs  and  pleura. 

Examination  of  these  as  to — 

(a)  Symptoms — Number  of  respirations,  dyspucea.  pain,  cough, 
expectoration,  hsemoptysis,  &c. 

(&)  Physical  Signs — Inspection,  palpation,  percussion,  auscul- 
tation. 

Thorax,  Circulatory  System — 

Peripheral — Arteries ;    veins,   &c.     Pulse,    number,   character, 
variations. 

Central — Heart,  and  large  vessels  within  thorax. 
Examination  of  these  as  to — 

(a)  Symptoms — Cardiac  dyspnoea,  palpitation,  pain  at  precordia, 
syncope,  angina  pectoris. 

(&)  Physical  Signs — Inspection,  palpation,  percussion,  auscul- 
tation. 

Abdomen,  Digestive  System — 

Symptoms — Teeth,   tongue,   deglutition,  hunger,  thirst,  diges- 
tion, vomiting,  bowels. 
Physical  Signs — Inspection,  &c.,  of  abdomen.     Tumors.     Liver 
and  spleen. 


58  EXAMINATION    OF    MEDICAL    CASES. 

Abdomex,  Gexito-Fkixart  System — 
Frequency  of  micturition,  pain,  &c. 

Urine;   amount  in  24  hours,  sp.  gr.,  color,  reaction,  odor,  de- 
posits, chemical  qualities. 
Menstruation,  lactation,  pregnancy. 

Diagnosis — Full ;  including  causes  and  all  the  lesions  and  disorders 

arranged  in  order  of  importance  and  succession. 
Progxosis — Immediate  and  remote. 

Tkeatmext — Principles,  indications  and  special  prescriptions. 
Progkess  axd  Termixatiox. 


THE  PERSONAL  HISTORY. 

Tlie  History  of  the  illness  under  observation  should,  as  a 
rule,  be  taken  sepai'ately  from  the  record  of  the  previous 
health  of  the  patient.  We  begin  by  seeking  to  know  what 
symptom,  or  combination  of  symptoms,  or  what  circum- 
stance has  brought  the  patient  into  the  hospital,  or  made  him 
seek  medical  advice.  The  points  regarded  by  the  person 
himself  as  important  are  thus  obtained,  and  should  always 
be  recorded  at  the  beginning  of  our  reports,  even  although 
they  may  not  seem  to  us  the  most  essential  features  of  the 
illness.  The  subsequent  course  of  the  case  has  often  much 
light  thrown  upon  it  by  this  record  of  these  early  indica- 
tions, for  the  patient  may  feel  the  importance  of  certain 
things  which  may  be  overshadowed  in  our  minds  by  con- 
siderations based  on  our  theoretical  view  of  the  disease. 

Taking  these  leading  complaints  as  our  basis,  we  try  to 
discover  the  date  at  which  they  appeared,  the  order  and  se- 
quence of  the  symptoms,  and  the  relative  severity  of  the 
different  parts  of  the  illness  at  different  times,  and  particu- 
larly the  date  at  which  the  disease  laid  the  person  aside  from 
work,  and  confined  him  to  the  house,  or  to  his  bed,  as  the 
case  may  be.  Having  traced  the  date  and  origin  of  the 
present  complaints,  we  seek  to  ascertain  if  they  arose  in  the 
midst  of  health-,  or  if  they  sprang  out  of  some  previous  ill- 
ness or  general  derangement.  If  it  appears  that  the  patient 
regards  the  present  trouble  as  definitely  originating  in  some 
other  illness,  or  if  from  the  known  facts  of  disease  this  re- 
lationship seems  probable  to  ourselves,  we  begin  our  history 
of  the  joresent  illness  with  an  account  of  the  former  one  out 
of  which  it  has  seemed  to  spring.  But  if  the  present  illness 
cannot  be  well  defined  by  a  date  of  previous  health,  or  if  the 
history  is  entangled  in  a  long  story  of  former  disease  or 
general  delicacy,  it  usually  conduces  to   simplicity  to  begin 


HISTORY    OP    THE    PATIENT.  59 

by  taking  tlie  history  of  the  present  aggravation  of  the  con- 
dition separately,  and  to  inchide  the  former  part  of  the  ill- 
ness in  the  account  of  the  previous  health  of  the  patient. 
For  example,  if  we  find  that  dyspnoja,  dropsy,  etc.,  consti- 
tute the  chief  complaints  of  the  patient,  if  these  have  ex- 
isted for  two  or  three  months,  and  seem  to  date  from  a 
second  attack  of  rheumatic  fever,  six  months  ago,  we  begin 
Avith  this  second  attack  of  rheumatism,  we  trace  the  sequence 
of  events  from  it,  and  reserve  a  detailed  account  of  iha  first 
rheumatic  attack,  and  any  former  illness,  for  the  other  part 
of  the  case  which  deals  with  the  previous  history  of  the  pa- 
tient. But  if  we  find  a  serious  haemoptysis,  or  a  violent 
pain  in  tlae  chest,  or  severe  headache  and  vomiting  to  form 
the  obvious  and  urgent  complaint  of  a  patient  on  admission, 
we  deal  first  with  the  origin  and  course  of  these,  even  al- 
though it  may  be  certain  that  the  patient  has  long  been  tlie 
victim  of  chronic  lung  disease.  Having  traced  the  history 
of  these  urgent  features  of  his  complaint,  we  go  back  and 
try  to  unravel  the  tangled  web  of  chronic  ill  health  in  all  its 
various  manifestations. 

In  the  case  of  children,  and  especially  of  young  children, 
we  may  often  save  time  by  ascertaining  from  the  mother  the 
point  in  the  child's  age  up  to  which  it  Avas  regarded  as 
healthy.  We  may  note  in  passing  Avhether  the  child  was 
suckled,  or  how  it  was  fed,  when  it  Avas  weaned,  when  denti- 
tion began,  and  when  the  child  began  to  Avalk.  From  this 
period  of  health  we  trace  all  its  illnesses  onwards,  up  to  the 
pi'esent,  even  although  there  may  not  be  much  connection 
between  them.  If,  again,  the  child  has  been  delicate  from 
birth,  or  troubled  Avith  many  recurring  illnesses  from  the 
beginning,  it  is  equally  important  to  procure  a  connected 
history  of  all  these,  so  as  to  judge  of  the  child's  prospects  in 
the  present  attack  of  Avhatever  kind  this  may  be. 

In  procuring  the  history  of  an  illness  from  the  patients  or 
their  friends,  we  should  try  to  get  the  facts  as  known  or  ob- 
served by  themselves,  rather  than  mere  names  received  from 
others  or  theoretical  conceptions,  such  as  "  inflammation," 
"  brain  fever,"  and  the  like.  Calling  an  illness  "  Rheuma- 
tism," for  example,  may  quite  mislead  us  in  the  history  of 
cases  which  really  depend  on  spinal  meningitis  or  locomotor 
ataxy.  We  must  try  to  learn  from  the  patient  or  his  friends, 
in  such  a  case,  Avhat  evidence  there  Avas  of  the  so-called 
rheumatic  attack,  whether  it  was  associated  Avith  swelling  of 
the  joints,  Avhere  the  pain  was  localized,  whether  there  was 


60  EXAMINATION    OF    MEDICAL    CASES. 

fevei'isliness,  and  so  forth.  The  stoiy  of  an  inflammation  of 
the  chest  or  lung  must,  likewise,  be  recorded,  with  such  ad- 
ditional information  as  can  be  obtained  ;  this  may  tend  to 
confirm  or  to  throw  doubt  on  the  name  given.  Sometimes, 
however,  when  the  name  of  the  disease  is  given  with  some 
precision,  and  stated  on  the  authority  of  some  medical  man, 
or  in  connection  with  some  hospital,  we  may  accept  the 
name  of  the  disease,  adding  in  our  notes  the  authority  on 
which  we  do  so. 

In  following  up  the  sequence  of  symptoms  we  also  aim  at 
representing  in  our  report  the  facts  of  the  illness  as  actually 
experienced  and  complained  of  by  the  patient,  apart  from  all 
theoretical  views  ;  some  patients  are  very  fond  of  importing 
these  into  their  narrative.  The  reality  or  severity  of  certain 
symptoms  may  often  be  usefully  indicated  by  stating  special 
facts,  for  example,  in  a  case  of  swelling  of  the  belly,  that  the 
skirts  had  to  be  widened,  or  that  the  trousers  could  not  be 
buttoned ;  or  in  a  case  of  weakness,  that  the  person  could 
not  walk  across  the  floor  without  assistance  ;  or  in  the  case 
of  pain,  that  the  patient  could  get  no  sleep,  or  that  he 
screamed  out,  or  fainted  in  connection  with  it.  Details  like 
these  guide  our  estimate  of  the  value  of  the  history  as  de- 
rived from  the  patient.  We  must,  likewise,  make  use  of 
our  own  knowledge  to  check  the  patient's  history,  particu- 
larly in  putting  special  questions  to  make  sure  of  the  real 
facts  when  the  account  seems  improbable  or  incredible.  We 
may  also,  after  getting  the  history  from  the  patient,  inquire 
as  to  whether  certain  symptoms  were  not  present,  as  he  may 
have  forgotten  them,  but  we  must,  if  possible,  avoid  putting 
ideas  into  our  patients'  minds ;  leading  questions  must  be 
sparingly  used,  or  at  least  reserved  for  the  end  of  the  inter- 
rogation, and  to  bring  out  negative  points  in  the  case  with 
clearness  and  precision. 

The  history  of  the  previous  health  should  be,  in  part,  of 
a  general  kind,  such  as  patients  can  readily  supply ;  the 
dates  and  durations  of  previous  illness  should,  as  a  rule,  be 
specified,  as  well  as  the  names  of  the  diseases  ;  the  general 
state  of  the  strength,  and  the  date  of  any  deterioration  in 
this  respect  must  likewise  be  noted.  But  in  addition  to  this 
general  sketch  we  must  often  put  special  questions  as  to 
special  points,  which  the  patient  might  otherwise  overlook. 
Tlius,  in  cases  of  heart  disease,  we  always  inquire  about 
rheumatism  ;  the  indications  of  this,  especially  in  childhood, 
are  often  so  slight  that  they  might  easily  be  missed  without 


HABITS    OF    THE    PATIENT.  61 

some  special  inquiry.  In  cases  of  spinal  paralysis,  aneurism, 
and  some  other  affections,  we  must  inquire  for  any  strain  or 
injury,  and  we  note  its  date  and  the  exact  manner  in  which 
it  hai)pened.  We  must  often,  indeed,  go  hack  upon  the 
history  of  our  patients,  especially  as  regards  this  earlier  por- 
tion of  it,  after  the  examination  of  the  case  in  various  ways 
has  guided  us  so  far  to  the  diagnosis.  Sometimes,  more- 
over, as  described  in  the  section  on  "  Family  History"  (see 
p.  65),  we  must  search  about  in  our  questions  for  diseases 
allied  to  the  one  suspected  to  exist,  using  popular  names 
likely  to  be  known  by  the  patient  or  his  friends. 

The  inquiry  as  to  previous  venereal  diseases  is  often  im- 
portant, but  must  be  approached  with  delicacy  in  the  case  of 
women,  especially  those  who  are  young  and  apparently 
respectable.  We  may  often  gain  some  information  as  to 
syphilis  in  an  indirect  way,  by  inquiring  for  a  history  of 
sore  throat,  skin  eruptions,  nodes,  and  falling  out  of  the 
hair  ;  or,  in  the  case  of  those  who  have  had  cliildren,  whether 
any  of  these  were  born  dead,  whether  there  had  been  any 
miscarriages,  whether  the  children  born  alive  had  eruptions 
on  their  buttocks,  snuffles,  or  the  like.  We  can  seldom 
place  much  reliance  on  the  mere  denial  of  syphilis,  but  with 
tact  in  approaching  the  subject  we  can  often  obtain  the  his- 
tory and  date  of  infection.  The  history  of  gonorrhoea  is 
important  in  certain  arthritic  affections,  and  particularly  in 
cases  of  urinary  irritation,  as,  when  stricture  follows  it,  the 
bladder  and  kidneys  are  often  involved.  Syphilis  has  to  be 
considered  in  the  history  of  a  multitude  of  diseases — skin 
diseases,  nervous  affections  of  various  kinds,  disease  of  the 
liver,  amyloid  degeneration  of  the  liver  and  kidneys,  aneur- 
ism, and  other  forms  of  disease  of  the  bloodvessels,  laryngeal 
ulceration,  &c. 

Social  History :  Habits Certain  points  not  of  a  purely 

medical  character  are  usually  inquired  into,  in  addition  to 
the  bare  facts  as  to  age,  occupation,  residence,  marriage, 
&c.,  which  are  taken  in  all  cases  for  the  routine  purposes  of 
the  hospital  records ;  special  points  must  often  be  searched 
out.  The  age  may  suggest  a  comparison  between  the  alleged 
and  the  apparent  age.  The  occupation  may  have  to  be 
scrutinized  as  to  the  special  peculiarities  of  the  employment, 
and  the  exposure  to  evil  influences  known  to  beset  certain 
trades;  former  occupations  sometimes  explain  certain  ail- 
ments. The  residence  may  raise  questions  as  to  the  healthi- 
ness of  the  locality,  its  freedom  from  certain  diseases  and  its 
6 


62  EXAMINATION    OP    MEDICAL    CASES. 

exposure  to  others;. the  accommodation  in  the  particular 
Louse  may  also  have  to  be  investigated,  as  regards  its  cubic 
space,  its  water-supply,  drainage,  &c. ;  former  residences, 
exposure  to  malarious  influences,  to  tropical  climates,  &c., 
have  often  to  be  inquired  for,  and  the  results  must  in  many 
cases  be  recorded  even  when  they  are  negative.  The  etfect 
of  marriage,  its  date,  and  the  number  of  children  born  alive 
and  dead  must  also  be  recorded  ;  in  the  case  of  women  the 
number  and  date  of  miscarriages  and  abortions  should  also 
be  noted  in  some  part  of  the  report. 

The  kind  of  food  habitually  used  often  supplies  very  im- 
portant light  as  to  certain  diseases  :  the  use  of  tea  in  excess, 
or  to  the  exclusion  of  milk,  vegetables,  potatoes,  &c.,  often 
explains  scorbutic,  nervous  and  dyspeptic  disorders.  The 
excessive  use  of  tobacco  is  suggested  in  cases  of  cardiac  pal- 
pitation or  pseudo-angina  pectoris,  dyspepsia,  dimness  of 
vision,  and  other  nervous  troubles.  The  use  of  alcoholic 
stimulants  must  be  inquired  into  in  cases  of  liver  disease, 
renal  affections,  dyspeptic  complaints,  and  in  all  diseases 
characterized  by  delirium,  with  or  without  much  fever  ;  the 
history  of  any  previous  intemperance  often  explains  the  high 
delirium  present,  and  has  great  importance  in  the  prognosis 
and  the  treatment.  The  form  of  alcohol  used,  whether  beer 
or  spirits,  is  sometimes  a  matter  of  importance  ;  we  must 
likewise  ascertain  whether  a  somewhat  excessive  use  of  these 
was  of  daily  occurrence,  or  whether  the  excess  was  only 
during  an  occasional  outbreak  in  the  course  of  weeks  or 
months. 

The  regular  use  of  other  stimulants  or  sedatives,  especially 
opium,  chloral,  and  chloroform,  must  sometimes  be  inquired 
into. 

Tiie  practice  of  masturbation  is  to  be  inquired  for  with 
great  caution,  as  we  must  avoid  suggesting  the  idea  of  evil 
to  those  whose  minds  are  free  from  any  such  notions,  but  in 
certain  cases  of  epileptic  seizures,  in  certain  forms  of  cardiac 
palpitation,  and  in  some  cases  of  nervous  prostration  and 
spermatorrhoea  the  questions  must  be  put  with  clearness  in 
the  interest  of  the  patients,  for  their  warning,  quite  as  much 
as  for  the  benefit  of  the  diagnosis.  Excessive  venereal  in- 
dulgence, whether  within  the  married  state  or  not,  is  often 
responsible  for  nervous  disorders,  spinal  paralysis,  locomotor 
ataxy,  and  other  less  definite  forms  of  disease.  These  efi'ects 
are  moj-e  common  in  the  male  than  in  the  female. 


FAMILY    HISTORY.  ^63 


FAMILY  HISTORY. 

The  importance  of  family  history  in  throwing  light  on  the 
tendency  to  special  disease  is  well  shown  in  life  insiu-ance 
studies.  This  inquiry  embraces  a  note  of  the  age  of  the 
parents  and  of  the  brothers  and  sisters  of  the  patient,  and  of 
their  state  of  health  if  alive,  of  the  ages  at  which  any  such 
relatives  may  have  died,  the  nature  of  the  illnesses  they  have 
had,  and  the  diseases  which  caused  their  death.  Inquiries 
as  to  other  relatives  are  occasionally  important,  especially 
when  the  number  of  brothers  and  sisters  is  small,  or  the  in- 
formation regarding  them  obscure;  the  grand-parents,  and 
the  uncles  and  aunts  of  the  patients,  on  both  sides,  are  tlie 
most  important  in  this  respect.  In  going  beyond  these  to 
half-brothers  and  sisters,  to  nephews  and  nieces,  to  cousins, 
or  even  to  the  children  of  the  patient,  we  necessarily  in- 
troduce complications  from  marriage  ;  these,  however,  may 
sometimes  be  allowed  for  in  summing  up  the  inquiry. 

Xow  all  this  information  can  seldom  be  obtained  with  any 
feeling  of  accuracy,  and  in  hospital  practice  the  deficiencies 
are  enormous.  We  should  begin  by  getting  the  bare  facts 
as  to  the  size  of  the  family,  the  ages  of  those  living,  and 
the  diseases  and  ages  of  those  who  have  died.  In  some 
cases,  where  we  can  interrogate  the  mothers  of  children, 
with  suspected  syphilis  for  example,  we  should  also  try  to 
obtain  the  number  and  dates  of  the  miscarriages  and  still- 
births, ascertaining  whether  these  occurred  before  or  after 
the  birth  of  the  child  under  consideration.  The  further 
prosecution  of  the  inquiry  must  turn  upon  the  facts  thus 
elicited,  and  upon  the  other  facts  discovered  in  the  investi- 
gation of  the  illness.  Hence  we  often  revert  to  the  family 
history  at  the  end  of  the  inquiry,  to  bring  out  information 
on  special  points  as  to  the  health  or  history  both  of  the  living 
and  dead.  When  the  causes  of  death  alleged  are  doubtful 
or  unsatisfactory,  we  may  sometimes  judge  for  ourselves  from 
the  facts  of  the  illness  supplied  by  our  informants.  In  par- 
ticular, we  must  receive  with  great  reserve  tlie  deaths  set 
down  to  '"Teething,"  "Change  of  Life,"  "Childbirth," 
"  Cold,"  "  Inflammation,"  &c.  Many  deaths  are  set  down 
to  childbirth  or  change  of  life  although  they  w^ere  really  due 
to  phthisis,  which  had  led,  perhaps,  to  suppression  or  irregu- 
larity of  the  menstruation  at  an  early  age,  or  which  had  run 
a  rapidly  fatal  course  after  childbirth.  Regard  should  be 
had  to  the  age  at  which  such  a  death  occurred,  how  long  the 


64  EXAMINATION    OF    MEDICAL    CASES. 

confinement  had  been  survived,  liow  long  the  weakness  had 
lasted,  and  whether  it  was  associated  with  cough,  spitting  of 
blood,  or  other  suspicious  symptoms.  In  these  doubtful 
cases,  inquiry  as  to  the  collateral  branches  of  the  family  is 
important — e,  g.,  if  a  patient's  mother  is  reported  to  have 
died  from  a  cause  in  doubt  we  may  search  with  advantage 
into  the  history  of  the  maternal  uncles  and  aunts.  "Inflam- 
mation of  the  Lung"  and  "  Pleurisy"  must  be  scrutinized  in 
the  same  way,  especially  if  other  deaths  occurred  from  phthisis 
or  pulmonary  affections  in  the  same  family ;  if  either  pleurisy 
or  pneumonia  proved  fatal  after  a  prolonged  illness,  we  may 
suspect  that  these  were  allied  to  phthisis,  or  that  some  scro- 
fulous tendency  existed  in  the  constitution  of  the  victim. 
The  name  of  "  Bronchitis"  also  covers  many  deaths  from 
phthisis  :  the  age  of  the  subject,  the  duration  of  the  illness, 
and  the  occurrence  of  lividity,  dropsy,  &c.,  may  sometimes 
guide  us.  "Worm  Fever,"  "Intermittent  Fever,"  "the 
dregs  of  the  measles,"  and  some  other  terms  of  this  kind  are 
often  merely  popular  names  for  tubercular  disease.  Sudden 
deaths  ascribed  to  apoplexy  are  to  be  investigated  as  to 
Avhether  the  death  was  almost  instantaneous  or  whether  the 
illness  lasted  at  least  some  hours  :  in  the  former  case  cardiac 
or  aneurismal  disease  is  more  probable  than  apoplexy;  apo- 
plectic attacks  in  early  manhood,  with  one-sided  paralysis, 
are  to  be  suspected  as  due  to  syphilitic,  cardiac,  or  renal  dis- 
ease. In  fact,  the  name  must  be  regarded,  unless  substan- 
tiated by  good  evidence,  as  of  only  little  account ;  all  the 
kno^\'ledge  we  possess  of  the  nature  of  diseases  and  their 
relative  frequency  at  particular  ages,  and  in  particular  coun- 
tries, must  be  brought  to  bear  on  the  scrutiny,  and  some 
familiarity  with  the  names  of  diseases  in  common  use  among 
the  poor  is  also  of  much  value  in  hospital  inquiries. 

In  inquiring  into  the  illnesses  which  the  members  of  a 
family  may  have  had,  it  is  desirable  to  suggest  various  dis- 
eases allied  to  the  one  known  or  suspected  to  exist  in  the 
patient,  using  for  this  purpose  various  names,  so  as  to  meet 
the  limited  knowledge  of  our  informers,  and  also  to  refresh 
their  memories.  Thus  in  regard  to  scrofulous  diseases,  we 
ask  for  swollen  glands  or  "waxen  kernels,"  or  runnings  in 
the  neck,  diseases  of  the  spine  and  other  bones,  bad  joints, 
white  swellings  or  "incomes,"  as  they  are  termed  in  Scot- 
land, disease  of  the  glands  of  the  bowels,  water  in  the  head, 
consumption  of  the  lungs,  or    decline,  or  weakness  of  the 


FAMILY    HISTORY — ALLIED    DISEASES.  65 

chest  witli  spitting  of  blood,  and  so  on,  we  may  in  this  way 
get  at  the  facts  when  a  more  general  question  fails.  It  is 
wise,  also,  in  many  cases  to  avoid  disagreeable  woi-ds,  such 
as  scrofula,  in  the  first  instance  at  least,  as  many  people  are 
so  annoyed  at  the  suggestion  of  such  affections  being  in  their 
family  that  they  feel  shy  of  giving  any  detailed  information. 
In  inquiring  for  a  family  history  of  cancer,  we  should  like- 
wise be  chary  of  mentioning  this  dreaded  name,  at  least  if 
our  patient's  disease  is  only  of  doubtful  malignancy,  trying 
rather  to  get  our  informants  to  volunteer  statements  on  the 
subject,  and  searching  for  the  information  wanted  under  the 
names  of  growths,  tumors  in  the  breast  or  elsewhere,  disease 
of  the  liver,  stomach,  or  womb,  with  wasting,  jaundice, 
dropsy,  floodings,  &c. 

We  must  further  bear  in  mind,  in  these  inquiries,  the 
variations  of  allied  diseases  which  appear  in  different  mem- 
bers of  the  family,  and  in  different  generations  ;  by  asking 
for  such  by  name  we  often  refresh  the  memory  of  our  inform- 
ants. Heart  disease,  rheumatism,  chorea,  psoriasis,  and  some 
other  cutaneous  affections,  and  perhaps  renal  concretions,  and 
em])hysematous  bronchitis,  appear  to  replace  each  other  in 
different  members  of  the  same  family.  The  scrofulous  group 
has  been  already  referred  to.  The  neurotic  group  includes 
the  various  forms  of  neuralgia,  epilepsy,  hypochondriasis, 
hysteria,  and  insanity;  apoplexy  and  hemiplegia  may  (per- 
haps doubtfully)  be  included  in  this  group,  their  hereditary 
character  seems  rather  to  be  associated  with  vascular  dis- 
orders. Gout,  disease  of  the  liver,  contracted  kidney,  renal 
calculus  and  gravel,  and  angina  pectoris  form  another  allied 
group  ;  and  these,  have  also  some  aflfuiity  with  the  disorders 
connected  with  arterial  degenerations.  Syphilis,  which,  of 
course,  has  marked  hereditary  characters,  assumes  such  a 
multitude  of  forms  as  to  preclude  enumeration,  but  the  ten- 
dency is  for  such  syphilitic  diseases  to  fail  in  the  course  of 
time  from  early  death  or  sterility.  Abortions,  still-births, 
early  deaths  in  infancy  associated  with  cutaneous  eruptions 
on  the  buttocks,  and  with  snuffles,  are  important  in  many 
family  histories ;  nervous  deafness,  opacities  of  the  cornea, 
notched  teeth,  epilepsy,  and  imbecility  are  occasional  mani- 
festations of  the  same  disorder  in  those  children  who  survive; 
in  adult  subjects  who  have  acquired  syphilis  we  must  either 
put  the  question  of  infection  directly  or  investigate  their 
symptoms  and  condition  when  the  question  of  syphilis  is 
important  in  the  family  history  we  are  studying. 

6* 


66  EXAMINATION    OF    MEDICAL    CASES. 

Although  family  history  is  chiefly  useful  in  detei-mining 
the  tendency  to  certain  chronic  and  constitutional  affections, 
or  to  premature  decay  of  the  individual  or  of  certain  organs, 
we  find,  likewise,  a  tendency  in  some  families  to  special 
fevers — enteric  fever,  for  example — and  even  to  certain  de- 
grees of  severity  or  to  special  complications — as  intestinal 
hemorrhage — and  this  may  guide  us  at  times,  esi)ecially  in 
prognosis.  The  hemorrhagic  diathesis  itself  is  sometimes 
clearly  hereditary. 

But,  supposing  we  have  fairly  collected  all  the  information 
above  indicated,  certain  precautions  are  required  in  drawing 
our  inferences.  These  are  due  to  hereditary  diseases  missing 
at  times  the  parents  of  our  patient,  or  even  the  whole  gene- 
ration ;  or  to  the  diseases  in  question  only  appearing  at  ages 
beyond  those  available  in  the  study  of  our  patient's  history  ; 
or  to  the  membei-s  of  the  family,  who  might  have  been 
affected,  having  been  cut  off  by  accident  or  by  what  may  be 
termed  accidental  disease  (fevers  and  many  acute  diseases). 
A  large  family,  with  all  the  living  members  grown  up  to 
middle  or  advanced  life,  should  show  pretty  clearly  the  ten- 
dency of  their  family  constitution,  but  even  then  cancer,  for 
example,  is  so  notoriously  disposed  to  appear  at  the  later 
periods  of  life  that  it  may  be  absent  from  the  family  history 
at  the  time  we  are  in  search  of  it.  A  child  may  die  of  can- 
cer supposed  to  be  quite  unknown  in  the  family  till  perhaps 
its  parent  dies  of  the  same  disease  many  years  later.  This 
defect  might  be  supposed  likely  to  be  supplemented  by  the 
history  of  the  uncles  and  aunts,  or  of  the  grand-parents  or 
the  grand-uncles  and  aunts  of  our  patient ;  but  there  is  first 
of  all  the  difficulty  of  getting  precise  information,  and  even 
then,  unless  the  numbei's  be  large  in  such  families,  we  may 
readily  miss  the  evidence  of  a  family  taint.  In  tubercular 
disease,  likewise,  especially  in  children,  the  family  tendency 
may  not  have  had  time  to  manifest  itself  at  tlie  date  of  our 
inquiry.  The  number  and  ages  of  those  living  come  in  here 
to  enable  us  to  guess,  as  it  were,  at  the  probabilities  of  such 
a  tendency  having  had  time  and  opportunity  to  manifest 
itself,  if  really  present.  A  deceptive  appearance  of  sound- 
ness in  the  family  history  may  sometimes  arise  from  there 
being  no  account  of  deaths  or  illnesses  connected  with  the 
suspected  disease,  when  really  from  smallness  in  the  number 
of  the  family,  or  from  deaths  due  to  fevei's,  &c.,  no  opportu- 
nity was  allowed  for  the   disease  to  show  itself.     Such  a 


FAMILY    HISTORY,    FALLACIES.  67 

family  history,  although  not  "bad,"  is  not  "goo-l;"  it  is 
defective  in  its  evidence.  In  a  larger  family,  again,  a  stray 
death  may  have  occurred  from  phthsis  or  rheumatism,  due, 
perhaps,  to  exceptional  exposure  or  unfortunate  modes  of 
life,  although  no  great  tendency  to  such  disease  existed  in 
the  family.  We  must,  therefore,  consider  all  these  points  in 
trying  to  form  a  sound  judgment. 


68 


CHAPTER  III. 

TEMPERATURE— PULSE— GENERAL  SIGXS  OF 
PYREXIA.' 

TEMPERATURE. 

Ax  increased  heat  of  the  body  is  one  of  the  oldest  and 
most  widely  recognized  signs  of  fever.  It  may  be  estimated, 
roughly,  by  applying  the  hand,  or  perhaps  the  back  of  the 
hand  to  the  surface  of  the  patient's  body,  selecting  some  of 
the  sheltered  parts,  such  as  the  axilla,  the  groin,  and  espe- 
cially the  abdomen.  It  must  be  borne  in  mind  that  a  certain 
coldness  of  the  extremities  and  of  the  exposed  parts  may 
coexist  with  a  great  elevation  of  the  temperature  in  the  in- 
terior of  the  body,  and  even  in  the  axilla  or  groin.  The 
variable  temperature  of  the  observer's  hand,  moreover,  must 
be  remembered  as  a  fruitful  source  of  fallacy,  so  that  when 
we  aim  at  accuracy  in  determining  the  degree  of  pyrexia, 
or  at  certainty  in  pronouncing  its  absence,  we  must  have 
recourse  to  the  thermometer. 

Clinical  thermometers  should  be  sensitive,  and  should  have 
the  bulb  of  such  a  size  and  shape  as  to  be  adapted  for  intro- 
duction into  various  parts  of  the  body.  The  graduation 
should  be  on  the  stem  itself.  Accuracy  in  the  instrument  is, 
of  course,  desirable  in  all  cases,  and  is  especially  important 
if  any  great  deviation  from  the  usual  range  of  temperature 
happens  to  be  discovered.     Certificates  of  accuracy,  or  of 

'  Various  works  on  tlie  practice  of  medicine,  on  diseases  of 
children,  and  the  acute  infectious  diseases  must  be  consulted  for 
details  :  See  especially  Aitken  (as  regards  temperature)  ;  Vol.  L 
of  Reynolds's  System  of  Medicine ;  Murchison  on  Fevers,  &c. 
Wunderlich  in  his  Medical  Thermometry,  and  Burdon  Sanderson 
in  his  Handbook  of  the  Sphygmograph,  deal  with  these  subjects  in 
detail.  The  Sphygmograph  is  discussed  in  most  of  the  recent 
treatises  on  Physiology.  Galabin's  little  pamj^hlet  on  Bright's 
Disease  is  also  valuable,  and  Sph3-gmographic  tracings  are  now 
given  in  various  works  or  sections  of  works  dealing  with  heart 
disease.  See  also  Mahomed's  F'apers  in  Mediail  Times  and  Gazette. 
—1872,  Vol.  I. 


CLINICAL    THERMOMETERS.  69 

the  amount  of  error  in  the  scale,  may  be  obtained  by  send- 
ing the  instruments  to  be  tested  at  Kew  Observatory.  It  is 
very  important  to  have  the  observations  made  with  the  same 
instrument,  in  the  case  of  a  given  patient,  as  in  this  way, 
although  there  may  be  some  slight  error  in  the  instrument, 
the  changes  in  the  patient's  temperature,  noted  from  time  to 
time,  are  but  little  affected  by  such  errors  ;  the  variations  in 
a  patient's  temperature,  from  time  to  time,  are  usually  more 
important  in  the  case  than  the  absolute  height  of  the  reading 
within  half  a  degree  on  either  side.  If  the  self-registering 
maximum  thermometer  be  used,  care  must  be  taken  to  shake 
down  the  index  below  the  probable  temperature  of  the  patient, 
before  it  is  applied  ;  if  an  instrument  without  any  registering 
index  be  used,  care  must  be  taken  to  read  it  in  situ.  In 
applying  the  thermometer  to  the  Axilla,  the  following  points 
must  be  attended  to  :  if  there  be  much  sweat,  the  skin  should 
first  be  wiped  dry ;  the  bulb  should  be  introduced  deeply 
into  the  axilla,  under  its  anterior  or  pectoral  fold,  and  the 
arm  must  be  kept  close  against  the  thorax  ;  it  is  sometimes  a 
good  plan  to  make  the  patient  hold  the  arm  in  position  by 
means  of  his  other  hand,  or  by  lying  slightly  on  the  arm 
during  the  observation  ;  strong  muscular  effort  to  hold  tlie 
arm  by  the  side  is  apt  to  cause  a  hollow  in  the  axilla,  and  so 
to  remove  the  soft  parts  from  the  bulb  of  the  thermometer. 
We  may,  however,  require  some  one  to  hold  the  instrument 
in  position  if  the  patient  has  not  strength  or  intelligence 
enough  to  keep  the  arm  closely  applied ;  care  must  be  taken 
that  no  folds  of  the  underclothing  interpose  between  the  bulb 
and  the  skin  ;  it  should  also  be  seen  that  the  instrument  does 
not  slip  down  or  project  behind  and  beyond  the  axilla.  The 
thermometer  must  he  left  in  position  till  the  mercury  main- 
tains the  same  level  for  two  or  three  minutes.  The  time 
required  for  an  accurate  measurement  of  the  temperature  in 
the  axilla  depends  on  this  cavity  requiring  to  be  kept  closed 
long  enough  for  it  to  reach  its  maximum  heat,  as  this  may 
have  been  reduced  by  exposure  to  the  air ;  it  is  clear,  there- 
fore, that  a  very  different  length  of  time  may  be  required  in 
different  observations ;  the  only  accurate  method  is  to  see 
that  the  maximum  is  really  attained,  as  judged  by  the  sta- 
tionary position  of  the  mercury ;  a  stationary  position  for 
two  or  three  minutes  is  found  to  be  sufficiently  accurate  for 
ordinary  clinical  purposes.  When  self-registering  instru- 
ments are  intrusted  to  unskilled  persons,  who  cannot  read 
the  index,  fifteen  minutes  may  be  named  as  a  proper  time 


70  TEMPERATURE. 

for  the  application  of  the  instrument.  If  tlie  arm  be  kept 
closely  applied  to  the  side  for  fifteen  or  twenty  minutes  im- 
mediately before  tlie  thermometer  is  introduced  into  the 
axilla,  the  necessary  time  for  the  actual  observation  may  be 
shortened.  Heating  the  bulb  of  the  instrument  beforehand, 
to  a  temperature  near  the  blood-heat,  is  desirable  if  the 
weather  be  cold  or  the  bulb  be  large,  but  it  does  not  mate- 
rially lessen  the  time  required  for  the  observation. 

If  the  Mouth  be  used  for  testing  the  temperature,  the  bulb 
should  be  placed  under  the  tongue  and  the  lips  kept  shut, 
the  breathing  being  performed  through  the  nostrils.  The 
mouth  resembles  the  axilla  in  being  sometimes  open  and 
sometimes  shut,  and  similar  remarks  apply  to  it  as  to  the 
axilla.  The  mouth  may  often  be  used  with  advantage  for 
testing  rapidly  the  temperature,  in  an  approximate  manner, 
in  dispensary  or  private  practice.  Care  must  be  taken  that 
nothino-  very  cold  (as  ice)  has  recently  been  in  the  mouth. 

The  Rectum  gives  results  more  accurately  and  rapidly 
than  either  of  the  preceding,  and  it  is  sometimes  preferable, 
especially  in  the  case  of  children,  where  axillary  measure- 
ments are  often  irksome,  tedious,  and  unsatisfactory.  The 
bulb  is  oiled  and  introduced  two  inches  w'ithin  the  bowel, 
and  held  steadily  till  the  maximum  is  reached  ;  this  always 
occurs  in  two,  three,  or  four  minutes.  If  very  young,  the 
child  may  be  placed  on  his  left  side,  in  the  nurse's  lap,  with 
his  face  to  her  right  breast.  The  objections  to  the  rectum 
(apart  from  the  annoyance  and  exposure  involved)  are  the 
possible  compression  of  the  bulb  by  the  bowel,  the  chance 
of  the  bulb  being  inserted  into  hard  feces  and  so  prevented 
from  being  in  contact  with  the  bowel,  and  the  possibility  of 
its  being  affected  by  the  descent  of  fluid  feces  from  a  higher 
and  warmer  level  ;  in  any  of  these  cases  the  temperature  of 
the  rectum  itself,  which  is  what  we  desire,  may  really  be 
missed.  The  temperature  of  the  rectum  as  compared  with 
the  axilla  may  be  quoted  roughly  at  three-quarters  of  a  de- 
gree Fahr.  or  nearly  one-half  degree  centigrade  higher  than 
that  of  the  axilla. 

The  Vagina  yields  accurate,  and  rapid  results  with  the 
thermometer,  but  is  only  seldom  to  be  recommended  for 
clinical  observations;  the  temperature  in  cases  of  labor, 
uterine  diseases,  «fec.,  may  sometimes  be  thus  tested  with 
advantage.  The  Urine  sometimes  affords  rapid  and  useful 
information,  if  it  be  passed  into  a  vessel  slightly  heated,  and 


DIURNAL    VARIATIONS. 


•71 


if  the  temperature  be  immediately  taken  \yitli  a  sensitive 
registering  thermometer. 

The  time  of  day  at  ichich  the  temperature  is  taken  should 
be  noted,  or  at  least  clearly  understood.  The  human  tem- 
perature has  a  daily  range,  during  health,  of  two  or  three 
degrees  of  Fahrenheit's  scale  (say  a  degree  or  a  degree  and 
a  half  centigrade) :  the  range  is  more  marked  in  children 
than  in  older  persons :  the  temperature  rises  in  the  early 
morning  hours,  attains  a  maximum  in  the  afternoon,  and 
falls  so  as  to  be  at  its  minimum  an  hour  or  two  after  mid- 
night. In  fevers,  likewise,  there  is  a  daily  range,  the  mini- 
mum occurs  usually  some  time  about  4  A.  M. ;  the  daily  accent 
varies  somewhat,  beginning  usually  earlier  in  the  day  in 
severe  than  in  mild  cases,  but  as  a  rule  it  is  distinctly  mani- 
fest about  mid-day  or  towards  the  afternoon :  the  maximum 
may  be  expected,  most  frequently,  about  8  P.  M.  In  hectic 
fever,  and  in  certain  stages  of  enteric  fever,  the  morning 
temperature  is  often  nearly  normal,  although  the  afternoon 
and  evening  readings  may  be  very  high.  (See  Figs.  1  and 
6.)  Sometimes,  however,  the  type  is  "•inverted,"  the  tem- 
perature being  low  at  the  hours  at  which  it  is  usually  high. 
The  importance  of  having  the  observations  made  at  the  same 
hours,  so  as  to  have  them  comparable  with  each  other,  be- 
comes thus  very  apparent.     This  likewise  shoAvs  the  danger 


HECTIC  j    FEVjE 

;P:hThisis.| 


mniMstni 


iiininii 


Fig.  1. — Diurual  range  of  the  temperature  in  Hectic  Fever 

of  relying  on  one  observation  (especially  in  the  morning  or 
forenoon)  as  proving  the  absence  of  pyrexia.  In  some  dis- 
eases the  oscillations  follow  definite  rhythmical  courses  of 


12  TEMPERATURE. 

their  own  (as  in  quotidian,  tertian  (Fig.  5),  or  quartan  in- 
terniittents),  but  in  others  the  daily  oscillations  are  sudden 
and  erratic  (as  in  py;emia).  Frequently  repeated  observa- 
tions in  the  coui'se  ot"  tlie  day  reveal  some  curious  and  im- 
portant facts  in  the  history  of  the  temperature ;  in  this  coun- 
try, however,  only  two  or  thi-ee  observations  in  the  day  are 
usually  taken,  so  as  to  avoid  fatiguing  or  annojing  the  pa- 
tients. If  frequent  observations  are  to  be  made,  the  best 
hours  are  about  2,  6,  and  9  A.  M.,  12  noon,  3,  6,  9,  and  12 
P.  M. ;  and  special  readings  should  also  be  made  in  connec- 
tion with  rigors,  convulsions,  or  other  unusual  occurrences 
and  also  in  testing  the  effect  of  remedies,  or  of  any  special 
anti-pyretic  treatment. 

Normal  and  Abnormal  Temperatures  may  be  classified  as 
follows : — ^ 

(  350    Cent.  =  950     Falir.  ■)  Very  low,  or  Collapse  Tem- 

lielow  1 3go    cejjt_  ^  9(5_8o  palir.  ]  peratures. 

About      'M]h^  Cent.  =  97.7°  Falir.     Subnormal  Temperatures. 

Normal  37°  Cent.  =  98.6°  Fahr.    Normal  Temperature. 

Ai      .   (olf?^^!'     "^  inn" '"in  ^''^I'^'^Slicjhtly  above  Normal,  or 
About  <  3hO    Cent.     ^  100.4^  Falir.  >  c   f  t^  '!    -1    m  i 

(38P  Cent.     =  101.30  Fahr.  )  ^^1^-Febr>le  Temperatures. 

(  390    Cent.  =  102.20  Fahr.  )  Moderately  Febrile  Tempe- 

About  I  gg^o  Cent.  =  103.10  Falir.  )  ratures. 

,    (406    Cent.  =  104O      Fahr.  |  Highly  Febrile    Tempera- 

"^^^^^^  (4010  Cent.  =  104.9°  Fahr.  j  tures. 

Above      410    Cent.     =  105.SO  Faln^  P^'P^^-P^^^^t^^^/^^P*'^^^^ 

Such  a  table  enables  us,  on  reading  the  thermometer,  to 
affirm  the  absence,  the  presence,  or  the  degree  of  pyrexia  in 
a  patient  at  a  given  time  ;  but  this  really  supplies  but  little 
information.  The  temperature  may  be  normal  and  yet  the 
patient  may  be  dying  or  may  even  be  in  the  midst  of  a 
dangerous  fever,  which  will  manifest  itself  in  the  course  of 
an  hour  or  two  as  a  burning  heat.  We  often,  however, 
detect  by  the  thermometer  a  degree  of  pyrexia  when  we 
have  but  little  expectation  of  doing  so,  judging  from  the 
patient's  pulse,  skin,  or  general  aspect ;  or  Avhen,  as  in  a 
rigor,  or  in  cholera  with  coldness  of  the  surface  and  extre- 
mities, an  inexperienced  person  would  think  a  febrile  heat 
impossible.  Very  high  or  very  low  temperatures  may  also, 
as  a  rule,  be  regarded  as  evidencing,  in  themselves,  a  danger- 

'  The  various  degrees  are  here  given  in  both  scales,  as  the  Cen- 
tigrade is  likely  to  come  into  more  general  use. 


NORMAL  AND  ABNORMAL  TEMPERATURES. 


13 


ous  condition.  Hyper-pyretic  temperatures  occur  as  serious 
complications  in  rheumatic  fever,  and  some  other  diseases, 
associated  usually  with  great  cerebral  disturbances.  Very  high 
temperatures,  lasting  but  a  short  time  just  before  death,  are 
not  uncommon  in  various  diseases.  (See  Fig.  2.)  Very  low 
temperatures,  however,  are  equally  or  even  more  common 
just  at  the  end.  (See  Fig.  3.)  Collapse  temperatures,  as 
taken  in  the  axilla,  are  sometimes  due  to  a  surface  depres- 
sion, so  that  if  we  wish  to  know  whether  the  internal  heat 
is  really  lowered  in  such  cases,  we  must  apply  the  thermo- 
meter to  the  rectum  or  vagina.  (Compare  terminal  tempe- 
ratures in  Fig.  7.)     The  thermometer  only  supplies  infor- 


16^-"  O. 


.PI.  ERPrtTJlL 

A  Ml^p  F  RMiCE 


•^V.---r 


ggot^rrrll 


Fig-  2. — Uuusually  high  temperature  just 
before  death. 


Fig'.  3. — Veiy  low  temperature 
just  before  death. 


mation  as  to  pyrexia  at  the  given  time;  its  indications, 
therefore  must  be  interpreted  with  due  caution,  and  in  view 
of  all  the  facts  of  the  disease. 

The  maimer  of  rise  in  the  temperature,  and  the  duration 
of  the  pyrexia,  with  regard  to  the  date  of  the  illness,  are 
7 


T4 


TEMPERATURE. 


often  most  valuaT)le  for  (iia<rnosis.  Some  diseases  are  remark- 
able for  the  rapidity  with  which  the  tem|)eratiire  rises.  Most 
of  the  short  fevers  or  lebriculte,  tis  they  are  called,  begin 
suddenly,  and  rapidly  attain  their  maximum.  (Fig.  5.) 
Amongt  these  are  the  surgical  febriculaj  (immediately  after 
operations),  and  the  feverisli  attacks,  associated  with  obscure 
and  often  transient  disturbances  of  the  general  health,  due 
to  disorders  of  the  digestive  organs,  especially  in  childhood. 
Tiie  following  likewise  usually  show  a  rapid  development  of 
pyrexia:  Suppurations,  and  most  of  the  diseases  ushered  in 
w^ith  severe  rigors,  ague,  tonsillitis,  acute  nephritis,  scai'la- 
tina,  smallpox,  pneumonia,  pleurisy,  peritonitis,  meningitis 
of  the  convexity,  rela])sing  fever,  erysipelas,  pya?mia,  paro- 
titis. All  of  these  may  have  very  Iiigh  temperatures  on  the 
first  day  of  the  illness.  Occasionally  in  malignant  cases  of 
smallpox  and  scarlet  fever  the  disease  proves  fatal  so  early 
that  the  svstem  is  overwhelmed  with  the  poison  and  never 
shows  any  febrile  heat.  Measles  sometimes  almost  reaches 
its  maximum  temperature  on  the  first  day  of  the  fever, 
although  a  marked  fall  usually  intervenes  between  this  and 
the  maximum  temperature  reached  on  the  fourth  or  fifth  day 
with  the  full  development  of  the  rash.  A  great  and  sudden 
elevation  of  the  temperature  is  so  common  in  the  diseases 
named  above  that  they  should  always  be  thought  of  in  doubt- 
ful cases. 

Other  diseases  are  rather  characterized  by  a  more  gi-adual 
and  progressive  elevation  of  the  temperature ;  this  is  espe- 
cially observed  in  enteric  fe- 
ver (Fig.  4),  although  excep- 
tional cases  of  this  disease 
occur  in  which  the  pyrexia 
attains  its  maximum  at  what 
seems  to  be  the  very  be- 
ginning of  the  illness.  But 
in  enteric  fever,  as  a  rule, 
tlie  elevation  is  such  that 
during  the  first  three  or  four 
days  every  day  marks  an  ad- 
vance on  the  previous  one, 
the  morning  temperature  fall- 
ing from  the  elevation  of  the 
previous  night,  but  being  in 
excess  of  that  of  the  previous  morning.  In  typhus  fever,  the 
advance  of  the  temperature  is  somewhat  more  sudden  than 


DAY  OF   FEVER  _ 

F.     I        2        3       4.       5  C.. 


Fiy.  4. — Gradual  rise  of  temperature  at 
the  begianiue  of  Enteric  Fever. 


CRISIS. 


75 


in  enteric,  but  in  it,  likewise,  several  days  usually  elapse  be- 
fore the  maximum,  or  any  very  high  point  is  reached.  In 
articular  rheumatism,  affecting  several  joints,  in  catarrhal 
pneumonia,  in  acute  tuberculosis,  and  phthisical  affections, 
the  ascent  of  the  temperature  is  usually  spread  over  several 
days. 

The  duration  of  the  pyrexia  often  assists  the  diagnosis. 
The  complete  and  continued  subsidence  of  the  temperature, 
within  a  week,  may  serve  to  exclude  typhus  and  enteric  fe- 
vers ;  its  prolongation  for  12  or  14  days,  Avithout  any  febrile 
rash  or  any  evidence  of  local  inflammatory  mischief,  may 
sometimes  guide  us  to  the  diagnosis  of -enteric  fever;  or  its 
persistence  may,  in  a  chest  complaint,  lead  us  to  the  diag- 
nosis of  phthisis  or  empyema. 


Fig.  5. — Temperature  ia  Tertian  Ague. 

The  decline  of  the  temperature,  both  as  regards  its  date 
and  manner,  is  of  the  utmost  importance  in  prognosis  and 
sometimes  in  diagnosis.  The  favorable  termination  of  a 
febrile  disease,  by  a  rapid  fall  of  the  temperature  to  the  nor- 
mal or  subnormal  level,  constitutes  a  Crisis.  This  fall  may 
amount  to  3  or  4  degrees  or  more  in  12  to  36  hours.  This 
method  of  termination  is  common  in  pneumonia  (lobar),  re- 
lapsing fever,  typhus,  smallpox,  tonsillitis,  facial  erysipelas, 
and  febriculaa  of  various  kinds.  It  suddenness- is  represented 
in  the  diagram  of  ague  (Fig.  5).     It  occurs,  however,  in  a 


76 


TEMPERATURE. 


modified  and  less  abrupt  manner  in  measles,  and  sometimes 
in  enteric  fever.  The  suddenness  of  the  crisis  varies  much 
in  different  diseases  and  even  in  different  cases  ;  in  many 
cases  of  typhus,  a  gradual  diminution,  extending  over  3  or  4 
days,  is  sometimes  so  marked  as  to  make  the  crisis  in  this 
disease  much  less  pronounced  than  is  usually  stated,  and  to 
assimilate  it  rather  to  a  lysis. 

Lysis  is  the  term  applied  to  a  more  gradual  diminution  of 
the  fever,  spread  over  several  days ;  this  may  usually  be 
observed  in  scarlatina,  broncho-pneumonia,  occasionally  in 
pleurisy  and  pericarditis,  and  also  in  acute  rheumatism. 
Sometimes  the  lysis  assumes  a  I'emitting  character,  the  morn- 
ing  temjieratures    falling    gradually  or    suddenly,  and   the 


12  .   15      14-    ,15      16      17 


cpJiviMlES-iENCE;  ■;■ 

ENlTERIC       "EVE  R,     : 

IN        A       OHI  LD.  -39' 

TEMR    IN    RECTUM- 


Fig.  6. — Remitting  Lysis  in  Enteric  Fever. 


evening  temperatures  preserving,  for  some  days,  nearly  their 
former  elevation.  This  is  not  uncommon  in  enteric  fever 
(see  Fig.  6). 

Certain  fallacies  beset  the  estimation  of  the  value  of  a  fall 
of  temperature.  It  is  very  often  found  that  a  high  febrile 
temperature  undergoes  a  great  diminution  on  the  day  after 
admission  to  the  hospital ;  this  seems  often  to  be  really  due 
to  an  unusual  elevation  on  the  day  of  admission,  from  the 
disturbance  of  moving  the  patient,  etc.  Occasionally  a 
l-seudo-crisis,  as  it  is  called,  occurs  a  day  or  two  before  the 
real  crisis,  the  temperature,  after  being  low  for  a  few  hours, 
mounting  up  again  to  its  former  height ;  this  pseudo-crisis 
affords  no  guarantee  of  a  subsequent  genuine  crisis.     Col- 


CRISIS    AND    LYSIS 


77 


lapse  temperatures  may  simulate  a  crisis,  although  really 
indicative  of  serious  complications,  as  in  the  intestinal  he- 
morrhage of  enteric  fever,  where  the  cause  of  the  fall  may 
not  at  first  be  quite  apparent.  The  fatal  termination  of  some 
cases  of  febrile  disease  is  often  associated  with  a  marked  fall 
in  the  temperature  (see  Figs.  3  and  7).  Colla[)se  tempera- 
tures may  occasionally  be  detected  for  a  few  hours  in  the 
midst  of  a  raging  fever,  or  just  before  the  terminal  exacer- 
bation of  a  febrile  disease,  whether  it  be  favorable  or  fatal. 
Sometimes  the  decline  of  temperature  in  a  tubercular  subject 
is  connected  with  the  supervention  of  cerebral  complications. 


Fig.  7. — Collapse  of  the  temperature  simulating  an  improvement.     Comparisoti 
of  axillary  and  vaginal  measuremeut.s  of  the  terminal  temperatures. 


Complications  and  Relapses  are  often  marked  by  a  re- 
ascent  of  the  temperature,  and  in  such  cases  the  rise  is 
usually  sudden.  Complications  may,  by  their  presence,  de- 
lay a  crisis,  as  is  often  seen  in  bronchitis  complicating  typhus, 
and  so  prolong  the  illness  ;  or  the  complication  may  impress 
a  remitting  character  on  the  fever,  as  is  seen  in  the  hectic 
fever  sometimes  developed  in  a  case  of  tubercular  pneumonia 
or  pleurisy.  The  temperature  of  convalescents,  however,  it 
must  be  remembered,  is  very  unstable,  and  there  is  often  a 
serious  looking  disturbance  of  the  temperature  in  them  from 
very  slight  causes  (indigestion,  constipation,  fatigue,  excite- 
ment, &c.),  which  would  not  thus  affect  the  healthy.  For 
this  very  reason,  temperature  observations  in  this  stage  are 
highly  important,  as  affording  the  best  evidence  of  continued 
safety  or  the  first  alarm  of  threatened  danger. 

7* 


78  PTJLSE. 

From  %Yliat  has  been  said,  it  will  be  seen  that  the  tempe- 
rature, although  of  the  utmost  importance  in  diagnosis  and 
prognosis,  must  hot  be  regarded  too  exclusively,  or  apart 
from  the  other  facts  of  the  case  and  the  general  state  of  the 
patient.  The  natural  course  of  the  temperature  in  the  various 
diseases,  as  ascertained  by  experience,  must  be  kept  in  mind; 
an  elevation  or  a  special  behavior  of  the  temperature  may 
have  a  very  serious  significance  in  one  disease  and  very  little 
in  another.  The  comparison  of  the  temperature  with  the 
.pulse  often  serves  to  correct  our  views  of  each,  and  although 
they  usually  rise  and  fall  together,  certain  deviations  occa- 
sionally or  habitually  occur  in  special  diseases,  or  in  certain 
stages  of  such  affections,  which  are  of  the  greatest  signifi- 
cance. (For  example  in  the  beginning  and  the  end  of  enteric 
fever,  and  towards  the  end  of  tubercular  meningitis  ;  see 
Pulse,  p.  79.) 

THE  PULSE 

affords  such  valuable  indications  for  the  determination  of  the 
febrile  state,  and  for  estimating  the  general  strength  of  the 
patient,  that  the  noting  of  it  is  a  matter  of  routine  in  all  cases. 
Apart  from  fever,  however,  there  are  other  important  points 
to  be  attended  to  in  noting  the  pulse,  and  to  prevent  repeti- 
tion these  also  will  be  considered  here. 

The  frequency  of  the  pulse  is  not  difficult  to  estimate  ;  the 
pulsations  in  the  artery,  the  radial  by  preference,  are  counted 
for  a  quarter  or  half  a  minute,  with  the  aid  of  a  watch  fur- 
nished with  a  seconds  dial,  and  the  number  per  minute  is 
thus  calculated.  For  delicate  inquiries,  the  pulse  should  be 
counted  for  a  whole  minute,  or  even  for  two  consecutive 
minutes,  the  number  being  halved  of  course  in  stating  the 
result.  Other  points  also  must  be  attended  to  when  accu- 
racy is  desired.  The  normal  rate  of  the  pulse  varies  with 
age,  and  also  in  different  individuals  (according  to  tempe- 
rament) ;  in  the  adult  it  is  usually  stated  as  being  about  72, 
but  it  is  sometimes  higher  and  often  much  lower :  it  is  more 
rapid  in  childhood,  and  in  infancy  is  often  about  100,  apart 
from  disease.  In  the  same  individual  the  pulse  varies  with 
position,  both  in  health  and  disease,  the  rate  being  higher 
when  the  patient  is  standing  than  sitting,  and  higher  while 
sitting  than  lying  down  :  any  movement  or  exertion  tends  to 
increase  the  rate,  and  mental  excitement  is  particularly  apt 
in  some  people  to  make  it  rise  very  high.     Hence  in  esti- 


TEMPERATURE    AND    PULSE.  -    79 

mating  the  pulse  or  its  changes  from  day  to  day,  in  such  a 
delicate  inquiry,  for  example,  as  the  estimation  of  an  incipi- 
ent defervescence,  care  must  be  taken  to  have  results  really 
comparable,  and  not  to  compare  the  rate  of  the  pulse  Avhile 
the  patient  is  sitting  up  in  bed  with  that  obtained  on  a  pre- 
vious day  while  he  was  lying  still.  The  influence  of  meals 
is  also  very  great,  the  pulse  rising  considerably  after  a  full 
meal,  and  especially  after  the  use  of  stimulants  in  the  healthy 
state;  in  febrile  diseases,  however,  the  effect  of  stimulants  is 
often  to  reduce  the  pulse-rate  when  their  influence  is  bene- 
ficial. The  time  of  day  has  a  certain  influence  in  the  normal 
state,  even  apart  from  food  and  exercise  ;  the  pulse-rate  is 
lower  during  the  midnight  hours,  and  rises  in  the  early 
morning,  but  the  exact  time  of  these  changes  varies ;  they 
are  usually  later  if  occurring  in  febrile  diseases  than  in  the 
normal  state.  Sleep  has  a  tendency  to  reducp  the  pulse-rate. 
Considerable  tact  is  often  required  to  secure  a  fair  estimate 
of  the  pulse  ;  in  some  cases  we  obtain  the  best  chance  at  the 
beginning  of  our  visit,  counting  the  pulse  before  the  patient 
is  disturbed  in  any  way  by  speaking  or  moving  ;  or  perhaps, 
especially  if  he  be  a  child,  while  he  is  still  asleep.  With 
some  patients  again,  the  approach  of  any  stranger  sets  up 
the  pulse  to  such  a  height  that  we  must  wait  till  it  has  sub- 
sided. The  lowest  rate  we  can  obtain  is  the  most  reliable 
index  of  the  degree  of  fever.  A  fit  of  coughing,  or  the 
exertion  of  moving  or  sitting  up  for  the  purpose  of  ausculta- 
tion, &c.,  often  completely  spoils  the  value  of  the  pulse-rate 
as  a  gauge  of  pyrexia.  It  is  in  sucli  cases  that  temperature 
observations  come  in  as  a  v^aluable  check  (see  Temperature), 
and  these  often  assure  us  that  the  rapidity  of  the  pulse  is  due 
to  excitement,  general  weakness,  or  irritability  of  the  heart, 
apart  from  fever.  As  a  rule,  the  pulse  and  temperature  in 
febrile  cases  are  elevated  or  depressed,  and  rise  and  fall 
together;  but  striking  differences  occur  in  certain  cases. 
The  pulse  is  often  but  little  elevated  in  the  beginning  of 
enteric  fever,  at  a  time  when  the  temperature  is  very  high ; 
while  after  the  recovery  has  begun,  the  pulse  may  be  rapid 
from  weakness,  although  the  fever  temperature  has  com- 
pletely fallen.  In  cerebral  cases,  also,  the  relationship,  of 
the  pulse-rate  to  the  temperature  is  subject  to  special  varia- 
tions ;  the  terminal  stage  of  tubercular  meningitis  is.  often 
characterized  by  a  high  pulse  and  a  comparativ€.ly  law  tempe- 
rature. The  ratio  of  the  pulse-rate  to  the  frequency  of  the 
respiration,  is  sometimes  of  value  as  a.n  i'ndes  trf  the,  existence 


80  pujiSE. 

or  supervention  of  respiratory  disease.     (See   Respiration, 
Chapter  ix.) 

The  force  or  strength  of  the  pulse  often  guides  our  progno- 
sis, and  directs  us  in  the  treatment,  especially  as  regards 
stimulants.  It  is  not  easily  estimated  by  the  beginner  ;  it 
requires  experience  and  the  watching  of  cases  (especially 
febrile  cases),  from  day  to  day,  for  the  education  of  the 
fingers.  Sometimes  the  radial  pulse  gives  a  fallacious  idea 
of  weakness,  from  the  vessel  being  of  unusually  small  size 
(high  division  or  other  abnormality).  Pressure  on  the  arm 
from  the  patient's  position  in  lying  on  it  may  also  interfere 
■with  the  radial  pulse.  Moreover,  the  radial  arteries  on  the 
two  sides  are  often  of  very  diti'erent  size,  and  so  we  find  that 
errors  sometimes  arise  from  detecting  a  difference  due  merely 
to  an  accidental  change  in  the  observation — the  different 
arm  being  taken  instead  of  the  one  usually  felt.  In  doubtful 
cases  the  radial  or  other  arteries  on  both  sides  should  be  ex- 
amined, and  the  heart's  sounds  should  be  listened  to.  When 
the  pulse  is  really  very  weak,  the  first  sound  of  the  heart  is 
usually  diminished  and  sometimes  almost  suppressed,  the 
second  sound  remaining  distinct.  Differences  in  the  strength 
of  the  two  radial  or  other  pulses  are  often  of  value  in  diag- 
nosis, particularly  in  cases  of  aneurism  of  the  arch  of  the 
aorta,  giving  rise  to  more  or  less  obstruction  of  certain 
branches.  Sometimes  the  two  pulses  are  not  perfectly 
synchronous  from  similar  causes.  Occasionally,  also,  the 
diminution  and  obliteration  of  an  arterial  pulse  serves  to 
indicate  the  occurrence  of  embolism,  but  care  must  be  taken 
to  see  that  these  differences  are  not  due  to  unusual  distribution 
of  the  vessels.  A  survey  of  the  arteries  should  b(;  made, 
both  with  the  finger  and  eye,  when  judging  of  the  force  of 
the  pulse,  and  the  examination  should  not  be  limited  merely 
to  the  part  of  the  radial  artery  at  the  wrist ;  by  extending 
our  observation  we  may  detect  any  undue  rigidity,  twisting, 
or  unevenness  of  the  vessels.  Sometimes  other  arteries  must 
be  examined  to  satisfy  ourselves  on  this  subject ;  the  tempo- 
rals and  the  branches  of  the  thyroid  axis  are  selected  for  the 
purpose  of  testing  the  smaller  vessels,  the  brachials  and  the 
femorals  as  a  sample  of  the  larger. 

The  rhythm  of  the  pulse  is  in  health  perfectly  regular,  so 
that  any  deviation  from  this  should  be  noted.  Sometimes  there 
is  a  distinct  intermission,  a  loss  of  a  beat  at  regular  or  irregu- 
lar periods,  but  there  may  be  such  a  loss  in  the  radial  pulse 
without  any  corresponding  intermission  in  the  heart's  sounds  or 


IRREGULAR    PULSE.  81 

action  ;  there  mav  tluis  be  a  marked  difference  in  the  pulse- 
rate  as  counted  at  the  wrist  and  at  the  heart.  Or  the  irregu- 
larity may  consist  of  two  or  three  hurried  beats  followed  by 
a  succession  of  slower  ones,  or  in  the  occasional  occurrence 
of  one  or  two  weak  or  almost  suppressed  beats.  Sometimes 
tiie  pulse  varies  greatly  in  strength  throughout  a  given 
minute,  without  any  intermission  or  marked  change  in  the 
rhythm.  This  change  in  the  strengtli  of  the  pulse  in  certain 
cases  can  be  made  out  to  be  associated  with  the  respiratory 
movements,  or  with  the  occurrence  of  convulsions,  or  some 
other  visible  phenomena.  Tiie  significance  of  irregularity 
of  the  pulse  is  most  varied.  It  sometimes  affords  one  of  the 
first  indications  of  brain  mischief,  especially  in  children,  or 
of  incipient  pericarditis.  It  is  very  common  in  various 
forms  of  heart-disease,  at  all  ages,  especially  in  mitral  dis- 
ease, fatty  heart,  and  the  degenerations  incident  to  old  age. 
(See  Fig.  16,  p.  So.)  Apart  from  these,  however,  it  is  often 
due  to  functional  disturbances,  especially  such  as  are  asso- 
ciated with  indigestion,  flatulence,  &c.  A  more  serious 
form  of  disturbance  leads. to  the  intermission  found  in  typhus, 
and  other  fevers.  It  is  likewise  developed,  not  unfrequently, 
through  nervous  agitation,  in  certain  persons,  just  as  accel- 
eration of  the  heart's  action  or  fluttering  is  produced  in 
others  from  the  same  cause  ;  concentration  of  the  attention 
on  the  intermission  is  apt  in  such  cases  to  increase  the  irre- 
gularity. Some  persons,  apart  from  any  medical  knowledge, 
have  an  obscure  sensation  of  the  intermission,  which  causes 
a  start  or  a  shock.  In  states  of  debility,  during  convales- 
cence from  serious  diseases,  and  in  the  case  of  children  after 
enteric  fever,  for  example,  intermission  of  the  pulse  is  some- 
times associated  with  unusual  slowness,  and  is  specially  no- 
ticeable at  night.     This  does  not  imply  any  real  danger. 

Dicrotous  Pulse Somewhat  allied  to  the  rhythm  is  the 

curious  double  beat  in  the  pulse,  sometimes  felt  in  febrile 
cases.  It  is  not  uncommon  in  the  convalescence  from  typhus 
fever.  This  is  best  felt  by  applying  the  pulp  of  the  fingers 
very  lightly  over  the  vessel,  avoiding  any  such  pressure  as 
would  extinguish  the  weak  second  beat.  The  sphygmograph 
brings  out  this  dicrotism  very  clearly.  A  little  practice 
with  this  instrument  is  useful  in  educating  the  fingers  in  the 
recognition  of  dicrotism.     (See  Sphygmograph — Fig.  10.) 

The  pulse  of  unfilled  arteries,  characterized  by  a  sudden 
filling  up  of  the  artery,  followed  by  a  very  sudden  collapse 
of  the  vessel  under  the  finger,  often  enables  us  to  suspect, 


82  THE    SPHYGMOGRAPn. 

or  sometimes  even  to  diagnose,  incompetency  of  the  aortic 
valves,  on  feeling  a  patient's  pulse.  The  peculiarity  is 
brought  out  in  a  more  striking  way  by  raising  the  patient's 
arm  vertically  while  feeling  the  radial  pulse ;  visible  pulsa- 
tion throughout  the  arteries  in  such  cases  is  usually  veiy 
marked.  The  sphygmograph  gives  a  very  striking  and 
characteristic  rendering  of  this  pulse.  (See  Sphygmograph 
—Fig.  12.) 

A  thrill  in  the  pulse  can  often  be  felt  in  certain  cases  of 
cardiac  disease  (mitral  and  aortic  valvular  disease),  and  this 
also  is  sometimes  rendered  very  plainly  in  the  sphygmo- 
graphic  tracing. 

THE  SPHYGMOGRAPH 

is  an  instrument  designed  to  enable  the  pulse  to  register  it- 
self, and  so  affords  a  permanent  record  of  its  frequency,  its 
force,  and  above  all  of  the  characters  of  the  pulse  wave. 

The  essential  parts  of  the  instrument  are  a  spring  which 
rests  upon  the  artery  and  has  its  movements  communicated 
to  it;  and  a  lever  which  amplifies  these  movements  and 
records  them  on  a  strip  of  paper  carried  along  by  clockwork. 
Marey's  instrument,  with  slight  modifications,  is  the  one 
usually  employed,  and  as  it  can  be  seen  in  all  well  appointed 
hospitals,  no  detailed  account  of  its  mechanism  need  be 
given.  The  sphygmograph  to  be  used,  however,  should 
have  Mahomed's  modification  for  estimating  pressure.  The 
artery  for  which  it  is  specially  adapted  is  the  radial,  and  the 
point  at  which  it  is  most  advantageously  applied  is  just 
where  the  artery  crosses  the  styloid  process  of  the  radius. 
The  advantages  are,  that  the  vessel  is  here  very  superficial 
aud  supported  on  a  flat  firm  surface.  If  possible  the  patient 
should  be  in  the  recumbent  posture,  as  this  generally  assures 
the  most  tranquil  state  of  the  circulation,  and  great  care 
should  be  taken  that  the  humeral  artery  is  subject  to  no 
pressure  in  any  part  of  its  course.  Tlie  instrument  may 
also  be  applied  while  the  patient  is  in  the  sitting  posture,  his 
arm  resting  on  a  table  in  front  of  him.  We  search  care- 
fully for  the  exact  site  of  the  radial  artery,  and  having  found 
it  mark  its  position  with  ink.  We  lay  the  wrist  into  the 
cushion  devised  by  Anstie  to  keep  the  hand  steady,  with  the 
knuckles  touching  tlie  table  or  bed,  and  having  placed  the 
button,  which  the  spring  carries  at  its  free  extremity,  imme- 
diately over  the  artery,  we  buckle  the  instrument  to  the 
cushion  by  means  of  a  band  of  elastic  braid.     If  the  spring 


PULSE    WAVE.  83 

is  not  accurately  adjusted  over  the  artery,  we  may  shift  it 
about  a  little  without  undoing  the  instrument,  but  generally 
it  is  preferable  to  apply  the  sphygmograph  afresh.  After 
the  spring  is  adjusted,  we  connect  it  with  the  lever,  and  see 
that  it  is  working  properly,  before  any  attempt  is  made  to 
register  the  tracing  on  paper.  Great  care  must  be  taken 
that  the  spring  is  fairly  saddled  on  the  artery,  the  least 
deviation  to  the  side  deforming  the  tracing.  The  pressure 
must  also  be  very  nicely  regulated.  A  number  of  tracings 
with  varying  degrees  of  pressure  should  be  taken  at  a  time 
and  the  most  perfect  selected.  The  slips  on  wliich  the 
tracings  are  to  be  taken  may  be  prepared  in  several  ways;  a 
very  easy  method  is  to  blacken  tlie  pajjcr  in  the  smoke  of  a 
turpentine  liame  from  a  paraffin  lamp — foreign  note  paper 
answers  the  purpose  very  well — and  wlien  the  tracings  are 
taken,  the  patient's  name  and  the  date,  witli  the  pressure 
employed,  may  be  written  on  them  with  a  needle  or  other 
sharp  point,  and  they  are  then  varnished  by  dipping  them  in 
a  solution  of  shellac  in  rectified  spirits.  In  Marey's  instru- 
ment, the  tracings  may  be  written  with  pen  and  ink,  but 
the  above  method  gives  more  delicate  results.  Smoked 
glass  may  also  be  used  instead  of  paper. 

The  following  are  the  names  applied  to  the  various  parts 
of  a  pulse  tracing: — 


Fig.  S. 

a  Primary  or  Percussion  Wave,  h  Secondary  or  Tidal 
Wave,  e  Aortic  Notch,  c  Dicrotic  Wave,  d  Fourth  Wave. 

All  these  parts  are  represented  in  a  healthy  pulse  tracing; 
the  pressure  used  for  healthy  pulses  varies  from  1^  to  3  oz. 

In  the  Febrile  or  Dicrotic  pulse  the  tidal  wave  is  lost,  the 
aortic  notch  lowered  and  deepened,  and  the  dicrotic  wave 
increased.  The  pressure  employed  is  as  a  rule  less  than  in 
the  healthy  pulse. 


84  THE    SPIIYGMOGRAPH 

"When  the  aortic  notch  falls  very  low,  reaching  below  the 
level  at  which  the  upstroke  begins,  the  pulse  is  said  to  be 
Hyper-dicrotous. 


Fig.  9. — Healthy  pulse.     Pressure  3  oz.     Pulse  6S. 

The  pidse  of  Aortic  Regurgitation  is  large,  the  upstroke 
quite  vertical,  the  apex  pointed  and  well  produced,  the  tidal 
wave  as  a  rule  well  marked,  the  aortic  notch  low,  and  the 
dicrotic  wave  small. 


Fig.  10. — Febrile  or  Dicrotic  pulse.     Pressure  IJ  oz.     Pulse  112. 


Fig  11. — ffyper-dicrotons  pulse.    Pressure  2  oz      Pulsel23  . 


Fig.  12. — Pulse  of  Aortic  Regurgitation.     Pressure  2|  oz. 


PULSE    TRACINGS. 


85 


The  following  pulses  from  a  case   of  thoracic   aneurism 
show  a  marked  difference  on  the  two  sides. 


Fig.  13.— Right  Radial. 

The  Senile  Pulse  or  Pulse  of  Rigid  Arteries — Its  most 
marked  features  are  the  substitution  of  a  plateau  for  an  apex, 
and  the  unbroken  character  of  the  descent  line. 


Fig.  \i.—Left  Radial. 


In  Bright's  disease,   especially  of  the  chronic  type,  the 
tension  in  the   arterial  system  is  usually  much  increased. 


-Sinile  Pulse. 


Fig.  16. — Tracinr/  from  a  case  of  mitral  regurgitation,  showing  the  pulse 
irregular  in  force  and  rhythm. 

8 


8G  GENERAL     SIGNS    OF    PYREXIA. 

This  is  indicated  by  the  marked  tidal  wave,  by  the  small 
dicrotic  wave  occurring  high  up  in  the  diastolic  part  of  the 
tracing,  and  by  the  great  pressure  which  the  pulse  will  bear. 
The  following  tracing  from  a  patient,  10  years  of  age,  illus- 
trates these  characters. 


Fig.  17. — Fulse  tracing  from  a  /subacute  case  of  Bright' s  iHsease.    Pul.se  -Jb. 
Pressure  r>  oz. 


GENERAL  OR  CONSTITUTIONAL  INDICATIONS  OF  THE 
FEBRILE  STATE. 

In  addition  to  an  increased  temperature  and  a  rapid  pulse, 
there  are  certain  general  signs  of  fever  which  are  of  great 
value.  Flushing  of  the  face  is  common  in  fever,  but  care  is 
required  to  prevent  mistakes  in  judging  of  this,  as  the  color 
of  the  cheeks  varies  much  in  ditferent  persons,  and  such  an 
accident  as  lying  on  the  cheek  often  produces  a  local  flush, 
apart  from  fever ;  in  such  cases  the  thermometer  is  an  in- 
valuable guide.  Siveating  is  l)abitual  in  some  fevers  (enteric 
and  rheumatic  fevers),  and  is  common  in  certain  stages  of 
most  febrile  diseases ;  the  total  absence  of  sweat,  giving  the 
sense  of  a  dry  pungent  heat  to  the  hand  as  applied  to  the 
skin,  is  an  important  fact.  The  sweating  is  sometimes 
habitual,  as  in  the  night  or  early  morning  sweatings  of 
phthisis  ;  it  is  also  often  cold  and  clammy,  and  in  sucli  cases 
it  may  be  associated  with  bad  dreams  ;  this  combination  is 
common  in  cases  of  deep-seated  suppurations,  disease  of  the 
bones,  &c.  Sweating  is  sometimes  local,  as  of  the  head  in 
rickets  ;  or  of  one  side  of  the  body,  in  certain  affections  of 
the  sympathetic  nerve,  sometimes  apart  from  any  other  ob- 
vious disease,  and  sometimes  connected  with  aneurismal  or 
other  tumors  in  the  chest  or  neck.  Headache  and  pain  in 
the  back  are  very  common  in  nearly  all  the  acute  specific 
fevers  at  their  beginning,  and  one  or  other  is  usually  present, 
more  or  less,  in  all  febrile  states.  Pain  in  the  back  is  very 
specially  pronounced  in  cases  of  smallpox.  (Of  course  these 
pains  are  often  due  to  quite  different  causes,  see  Chapter  vi.) 


SniVERINGS.  -     87 

Unequal  distribution  of  heot,  a  feeling  of  heat  in  the  head 
and  cold  in  the  extremities,  a  burning  heat  in  the  hands  or 
the  feet,  a  sense  of  cold  water  trickling  down  the  back,  a 
feeling  of  chilliness  increased  on  any  exposure  to  a  draught 
of  cold  air,  and  actual  shiverings  in  all  degrees  of  their 
severity  are  exceedingly  common  in  the  beginning  of  febrile 
diseases,  especially  before  the  [)atient  has  taken  to  bed  ;  these 
sensations  often  lead  him  to  hang  about  the  fire-place,  com- 
plaining of  cold,  although  his  temperature  may  be  very 
high ;  they  tend  to  disappear  when,  by  proper  heating  and 
clothing  in  bed,  the  temperature  of  the  various  parts  of  the 
body  becomes  more  equalized.  While  shiverings  are  com- 
mon at  the  beginning  of  all  inflammatory  and  febrile  dis- 
eases, they  are  especially  frequent  and  repeated  in  ague,  in 
serious  suppurations,  in  renal  inflammation  and  renal  colic, 
in  cases  of  gallstones,  and  in  embolism  and  pya?mia.  Young 
children  seldom  have  distinct  shiverings.  Rigors  also  occur 
occasionally  in  connection  with  sudden  defervescence.  Many 
of  the  sensations  just  referred  to,  and  even  actual  shiverings, 
occur  apart  from  fever  altogether  in  nervous  subjects  ;  the 
thermometer  is  here,  again,  invaluable.  The  digestive  func- 
tions are  almost  always  imjjaired  in  febrile  diseases,  and  es- 
pecially at  the  onset  of  the  specific  fevers.  Vomiting  is 
very  common  in  the  last  named,  and  is  sometimes  very 
severe  and  persistent  (smallpox,  scarlatina,  and  occasionally 
enteric  fever)  ;  in  other  cases  slight  sickness  or  nausea  is  all 
that  is  complained  of.  The  appetite  is  almost  always  im- 
paired, and  often  completely  depressed.  The  bowels  are 
usually  disordered ;  the  febrile  state  tends,  as  a  rule,  to  pro- 
duce constipation,  but  occasionally  diarrhoea  is  seen  to  result 
from  the  action  of  the  specific  fever  (as  in  the  beginning  of 
malignant  scarlatina),  and  sometimes  there  is  a  special  con- 
nection between  the  diarrhoea  and  the  febrile  disease  (as  in 
ulceration  of  the  bowels  in  enteric  fever,  and  in  tubercular 
and  dysenteric  ulcerations)  ;  at  times,  however,  the  loose- 
ness of  the  bowels  seems  related  to  the  pyrexia,  as  such  and 
ceases  with  it.  The  state  of  the  tongue  reflects  the  consti- 
tutional disturbance  produced  by  the  fever  so  far  as  the  di- 
gestive organs  are  concerned.  (!3ee  Tongue,  Chapter  xi.) 
Thirst  is  almost  always  present  in  the  febrile  state,  especially 
at  the  beginning  of  the  illness,  and,  notwithstanding  the 
large  amount  of  fluid  swallowed,  the  urine  is  usually  scanty 
and  high-colored.  Ifuscular  prostration  is  present  in  all 
severe  cases  of  fever,  and  is  often  very  marked  even  at  the 


88  GENERAL    SIGNS    OF    PYllEXIA. 

beginning  of  some  of  the  specific  fevers.  Delirium  is 
usually  associated,  in  very  varying  degrees  however,  with 
high  ranges  of  pyrexia  from  whatever  cause  ;  the  degree  of 
it,  and  the  date  at  which  it  appears,  as  well  as  its  character, 
vary  much  in  different  diseases.  Convulsions  sometimes 
take  the  place,  as  it  were,  of  delirium,  especially  in  young 
children,  and  often  mark  the  beginning  of  acute  inflamma- 
tory or  febrile  diseases  in  them.  A  degree  of  bronchial 
catarrh  is  not  uncommon  in  nearly  all  serious  febrile  states, 
and  is  a  special  feature  in  some.  Cutaneous  eruptions  are 
characteristic  of  certain  febrile  diseases.  (See  Febrile 
Rashes,  p.  105.) 

The  CuNicAL  Significance  of  the  Febrile  State 
is  very  great,  and  this  remark  applies  both  to  the  presence 
and  absence  of  this  state  in  a  given  case.  It  has  already 
been  explained  how  the  febrile  state  is  to  be  judged  of;  the 
possibility  of  our  observation  occurring  in  an  apyretic  inter- 
val must  be  remembered  before  w^e  arrive  at  a  negative  con- 
clusion. Sometimes  the  fact  of  fever  (^.  e.,  pyrexia)  is  all 
that  can  be  made  out ;  but  without  denying  the  existence  of 
a  simple  continued  fever,  we  are  seldom  justified  in  resting 
satisfied  till  we  either  have  referred  the  pyrexia  to  one  of 
the  specific  fevers  (typhus,  scarlatina,  ague,  pertussis,  &c.), 
or  have  ascertained  that  it  is  symptomatic  of  some  special 
inflammation  (pneumonia,  pleurisy,  abscess,  rheumatism, 
&c.),  or  at  least  of  some  disease  known  to  be  associated  with 
febrile  disturbance  (phthisis,  tuberculosis,  syphilis,  &c.). 

(1.)  Specific  Fevers  and  Rashes — In  determining  this 
question,  attention  must  be  directed  to  the  presence  or  ab- 
sence of  the  "rashes"  found  in  most  of  the  specific  fevers 
(see  p.  105).  These  must  be  carefully  searched  for  in  their 
favorite  situations,  and  the  date  of  the  illness  must  be  con- 
sidered in  this  respect,  as  to  whether  there  has  been  time  for 
the  appearance  of  the  rash.  As  the  exact  date  of  the  illness 
is  often  obscure,  and  as  the  day  on  w^hich  a  febrile  rash  ap- 
pears deviates  occasionally  from  the  average  times  usually 
stated,  some  little  allowance  must  often  be  made  for 
such  variations  before  arriving  at  a  decision.  The  occa- 
sional absence  of  the  rash,  in  nearly  every  fever  usually 
characterized  by  an  eruption,  must  also  be  remembered. 
Other  circumstances  often  render  the  existence  of  such  fe- 
vers very  probable,  or  indeed  certain,  even  when  no  rash 
has  appeared.  In  examining  for  a  febrile  rash,  other  cuta- 
neous eruptions  (not  of  this  class)  may  be  detected,  and  it 


SIGNIFICANCE    OF    PYREXIA.  89 

must  be  considered  whether  the  eruption  discovered  is  of  the 
kind  and  of  the  extent  to  account  for,  or  to  be  in  harmony 
with,  the  febrile  movement.  Some  skin  diseases,  as  they 
are  called,  are  associated  with  much  fever,  others  with  little 
or  none.  The  possibility  of  an  eruption  from  the  use  of 
medicines,  and  the  influence  of  certain  articles  of  diet  must 
be  kept  in  view.  (See  Eruptions  from  Medicine  and  Food, 
p.  101.)  Moreover,  when  there  is  high  pyrexia,  a  certain 
congestion  of  the  skin,  especially  in  dependent  parts,  some- 
times simulates  a  scarlet  rash.  Eruptions  indicative  so  far 
of  certain  diseases,  although  they  cannot  be  called  specific, 
are  sometimes  found  in  the  febrile  state — such  as  herpes 
labialis  in  pneumonia,  or  miliary  vesicles  in  enteric  and 
childbed  fever,  rheumatism,  &c.  Occasionally  a  rash  is 
found  in  diseases  not  usually  characterized  in  this  way ; 
thus  we  may  have  a  rash  in  diphtheria  and  relapsing  fever, 
and  in  the  early  or  pre-eruptive  stage  of  smallpox  and  en- 
teric fever. 

(2.)  Injlammations When  no  specific  rash  exists,  and 

no  distinct  history  of  contagion  is  suggested,  search  must 
be  made  for  signs  of  inflammation,  and  although  the  case 
may  be  admitted  to  a  medical  ward,  the  possibility  of  super- 
ficial inflammations  or  abscesses,  periostitis,  otitis,  parotitis, 
and  other  glandular  inHammations,  must  never  be  forgotten, 
especially  in  the  case  of  children  or  those  unable  to  express 
their  sensations.  Tonsillitis,  quinsey,  pharyngeal  abscess, 
scarlatina,  and  diphtheritic  sore  throat  must  also  be  remem- 
bered in  this  connection.  Pain  and  its  situation  usually 
guide  us  to  these  and  similar  inflammations,  and  also  to 
articular  or  muscular  rheumatism.  Regarding  internal  in- 
flammations, the  importance  of  examining  the  chest  cannot 
be  overrated,  as  we  often  find  there  the  explanation  of  the 
febrile  disturbance.  This  must  never  be  neglected.  In- 
flammations of  other  internal  organs  usually  indicate  their 
existence  by  pain  over  the  parts,  or  by  changes  in  the  ex- 
cretions, or  by  other  alterations  in  the  functions,  such  as 
paralysis,  delirium,  &c.  A  systematic  search  must  be  made 
into  the  state  of  all  the  important  organs  before  arriving  at  a 
negative  conclusion. 

Shiverings  are  common  in  various  febrile  diseases,  espe- 
cially at  the  beginning ;  but  when  severe  and  recurring,  the 
idea  of  suppuration  somewhere  is  suggested,  or  perhaps  em- 
bolism and  pyaemia.  Such  suppurations  may  be  in  parts 
beyond  the  reach  of  our  diagnosis,  but  search  must  be  made 

8* 


90  GENERAL    SIGNS    OF    PYREXIA. 

for  tender  regions  in  the  principal  organs,  and  also  in  the 
joints. 

(3.)  Care  must  be  taken  not  to  conclude  at  once  that  the 
febrile  state  is  due  solely  or  chiefly  to  the  inflammation  which 
we  may  have  detected  by  our  examination.  For  example, 
bronchitis  is  an  habitual  accompaniment  of  typhus,  and  pneu- 
monia is  common  in  many  fevers.  Inflammation  or  conges- 
tion of  the  kidneys  (with  albuminuria)  is  a  frequent  compli- 
cation in  many  complaints.  It  is  often  difficult  to  know 
wliether  we  have  to  do  with  a  primary,  a  secondary,  or  a  mere 
coincident  inflammation  ;  the  date  of  the  illness,  and  the 
known  characters  of  the  disease,  often  assist  us,  and  the 
want  of  correspondence  between  the  apparently  slight  extent 
or  severity  of  the  inflammation  and  the  intensity  of  the  fever, 
sometimes  leads  us  to  suspect  that  there  is  something  behind 
the  local  inflammation. 


91 


CHAPTER  lY. 

SKm—HATR— NAILS— GLANDS— JOINTS.' 

CUTANEOUS  ERUPTIONS. 

Eruptions  on  the  skin  are  sometimes  brought  promi- 
nently under  our  notice  as  the  chief  part  of  the  patient's 
complaint,  or  at  least  are  so  obvious  that  they  cannot  be 
overlooked;  but  in  other  cases  we  have  to  search  carefully 
for  an  eruption  which  the  patient  may  be  unconscious  of,  or 
which  he  may  regard  as  quite  trivial  and  accidental.  Most 
of  the  cutaneous  eruptions  serve  to  indicate  the  presence  of 
some  constitutional  atiection  or  general  tendency.  Thus  the 
eruptive  fevers  present  on  the  skin  the  evidence  of  a  general 
disturbance  of  the  whole  system.  The  occurrence  of  early 
late  syphilitic  eruptions  likewise  reveals  a  constitutional 
atl'ection,  and  the  same  may  be  said  of  scrofulous  and  per- 
haps of  cancerous  diseases  of  the  skin.  The  pigmentations 
of  pregnancy  and  Addison's  disease,  the  blotches  in  scurvy 
and  purpura,  and  the  influence  of  certain  medicines  in  pro- 
ducing eruptions  of  various  kinds  all  indicate  the  same  thing. 
Eczema  and  psoriasis,  from  their  symmetrical  distribution, 
their  tendency  to  recur,  and  their  association  with  certain 
other  diseases  in  the  patient  himself  or  in  his  family,  can 

1  In  addition  to  the  works  on  general  medicine  and  diseases  of 
children,  we  must  also  refer  to  surgical  treatises  regarding  certain 
cutaneous  and  glandular  affections. 

For  the  Febrile  Eruptions,  see  especially  Reynolds's  System,  Vol. 
I.,  and  Murcliison  on  Continued  Fevers  (with  colored  illustrations 
of  Typhus  and  Enteric  Rashes). 

For  Skin  Diseases,  consult  the  works  of  Tilbury  Fox,  M'Call 
Anderson,  Neumann,  and  Hebra.  For  illustrations  of  these,  see 
the  Atlases  by  Tilbury  Fox  and  Erasmus  Wilson.  The  plates  issued 
by  the  New  Sydenham  Society  are  perhaps  the  most  accessible. 
See  also  Greenhow  on  Addison's  Disease. 

Regarding  Affections  of  the  Joints,  the  reader  may  refer  to  the 
articles  on  gout  and  rheumatism  in  various  medical  treatises,  and 
especially  in  Reynolds's  System,  Vol.  I.  ;  surgical  works  may  also 
be  referred  to  with  much  advantage,  especially  Holmes's  System, 
Vol.  IV. 


92  CUTANEOUS    ERUPTIONS. 

often  be  shown  to  be  much  more  than  mere  local  diseases. 
Even  parasitic  affections  of  the  skin  often  owe  tlieir  rapid 
development  and  persistency  to  the  general  state  of  the 
health  ;  the  vegetable  parasites  do  not  seem  to  find  a  suitable 
nidus  in  perfectly  healthy  subjects. 

These  remarks  are  designed  to  direct  attention  to  the  two 
great  points  in  the  study  of  cutaneous  eruptions — the  local 
condition  and  the  general  state.  The  general  derangement 
may  manifest  itself  by  changes  of  which  the  skin  affection  is 
but  one  out  of  many  ;  or  the  cutaneous  disease  may  be  the 
sole  manifestation,  or  at  least  the  chief  evidence,  of  the 
general  disorder.  On  the  other  hand,  affections  of  the  skin 
arising  purely  from  local  causes,  or,  as  more  frequently  hap- 
])ens,  aggravated  by  local  influences,  may  produce  a  general 
disturbance  of  the  whole  system. 

For  the  classification  of  skin  eruptions  the  most  satisfac- 
tory and  the  most  solid  system  would  be  one  based  on  their 
causation,  rather  than  on  their  special  forms.  Hitherto  this 
has  only  been  possible  to  a  slight  extent,  as  the  causes  of 
many  eruptions  are  unknown,  and  the  causes  of  others  are 
not  uniform,  or  perhaps  are  complex  and  indirect.  The  real 
cause  of  eruptions  must  be  kept  in  view,  however,  so  far  as 
this  is  possible.  It  is  of  the  utmost  importance,  for  example, 
to  know  whether  an  eruption  is  due  to  iodide  of  potassium, 
to  smallpox,  to  syphilis,  or  to  scabies:  any  system  which 
would  group  together  such  diverse  affections  as  "  papular" 
or  "  pustular,"  even  although  they  may  all  present  papules 
or  pustules,  tends  only  to  mislead.  And  further,  any  group- 
ing of  skin  eruptions  based  merely  on  the  elementary  lesions 
is  rendered  impossible  for  any  useful  purpose,  when  we  find 
scabies,  for  example,  presenting  at  different  times,  or  even  in 
different  parts  at  the  same  time,  such  diverse  lesions  as 
papules,  vesicles,  and  pustules ;  or  when  we  find  eczema  at 
one  time  papular,  at  another  vesicular,  at  another  pustular, 
and  at  another  somewhat  scaly;  or  when  we  find  syphilis 
assuming  every  variety  of  form. 

Still,  as  the  causes  of  eruptions  are  often  unknown,  and 
cannot  even  be  suspected  by  the  inexperienced,  Ave  avail 
ourselves  of  the  obvious  distinctions  afforded  by  the  peculi- 
arities of  the  lesion ;  and  when  nothing  more  can  be  done, 
the  student  may  at  least  describe  the  nature  of  the  lesion, 
the  extent  and  distribution  of  the  eruption,  and  the  genera 
and  local  symptoms  associated  with  it. 

The  Elementary  Lesions,  indeed,  formed  the  basis  on 


ELEMENTAllY    LESIONS.  ,93 

Avliich  Willan  and  Bateman's  classification  was  built ;  and, 
although  now  discarded,  like  most  of  the  old  nosological 
systems,  the  facts  on  which  it  rested  are  of  great  value  and 
ai"e  still  constantly  referred  to. 

Erythema^  is  a  simple  redness  of  the  skin,  fading  readily 
on  pressui*e,  and  not  extending  to  the  cellular  tissue.  (Ery- 
thema may  be  simply  symptomatic  of  adjacent  inflammation. 
Among  the  varieties  of  erythema  we  have,  E.  laive,  E.  in- 
tertrigo, E.  nodosum,  E.  fugax,  and  E.  gangrfenosum.) 

Wheals^  (pomphi)  are  well  represented  by  the  red  and 
white  elevated  patches  produced  by  the  sting  of  a  nettle,  or 
the  bite  of  a  bug,  or  even  of  a  flea;  in  slight  forms  the  white 
portions  may  not  appear ;  in  severer  forms  they  may  be  com- 
plicated with  blisters.  (Wheals  occur  in  urticaria  in  its 
acute  and  chronic  forms.  "  Factitious  urticaria"  is  the  name 
used  for  the  variety  produced  in  certain  persons  by  mechan- 
ical irritation.) 

Pajmlce.  are  pimples  of  various  sizes  and  forms  ;  they  may, 
however,  be  very  different  in  their  constitution.  (Willan 
and  Bateman  included  under  this  heading,  strophulus,  lichen, 
and  prurigo  ;  but  different  views  now  prevail.)^ 

Vesiculce  and  BuUce  differ  from  each  other  in  size,  the 
former  being  small  blisters  and  the  latter  large  ones.  They 
may  be  simple,  or  they  may  be  divided  so  as  to  be  compound. 
They  may  present  perfectly  clear  fluid,  or  they  may  contain 
inflammatory  products  to  a  variable  extent,  so  as  to  present 
all  degrees  of  turbidity — the  separate  vesicles  passing  through 
these  various  stages  ;  they  may  be  associated  with  all  degrees 
of  redness  of  the  adjacent  skin,  or  they  may  be  free  from  this 

'Willan  and  Bateman  had  an  order  named  "exanthemata" 
which  included  two  of  the  febrile  eruptions  (rubeola  and  scarlatina), 
and  also  roseola,  urticaria,  purpura  and  erythema.  Roseola  is 
now  usually  regarded  as  an  erythema  of  a  rose  color.  The  name 
"  Erythema,"  as  a  special  disease,  was  formerly  applied  to  cases  of 
the  slighter  forms  of  erysipelas. 

2  Strophulus  and  lichen  are  regarded  by  many  as  identical ;  but 
strophulus  is  a  vague  name,  including  various  different  eruptions  : 
it  is  not  always  papular,  and  seems  rather  to  be  connected  with  the 
sudoriparous  apparatus.  When  not  papular,  it  is  to  be  classed 
with  the  erythemata  ;  when  papular  it  need  not  be  separated  from 
lichen.  This  disease  again  is  regarded  by  many  as  a  form  of  ecze- 
ma (E.  papulosum  or  E.  lichenoides.)  Pruriginous  eruptions  are 
papular  ;  but  the  enlarged  papillae  are  often  irritated  and  abraded 
by  scratching.  "  Prurigo,"  in  this  sense,  is  a  valuable  indication 
of  itching,  as  in  scabies,  phtheiriasis,  and  urticaria.  Prurigo,  apart 
from  this,  as  described  by  Hebra,  is  rare  in  this  country. 


94  CUTANEOUS    ERUPTIONS. 

complication.  Several  may  coalesce  forming  large  blisters 
or  "  blebs."  (Under  "  vesiculas,"  Willan  and  Bateman  in- 
cluded varicella,  vaccinia,  herpes,  rupia,  miliaria,  eczema, 
and  aphtha ;  under  "  bullae,"  erysipelas,  pemphigus,  pom- 
pholyx.)'^ 

'  Vesicles  pass  rccadily  into  pustules,  so  that  some  diseases  might 
be  classed  under  either  or  both  orders.  For  varicella,  miliaria,  and 
erysipelas,  see  special  sections  pp.  109,  113, 114.  (Aphthae  are  little 
blisters  on  the  mucous  membrane  of  the  mouth.  See  Tongue, 
Chapter  xi.) 

Herpes  consists  of  an  eruption  of  small  vesicles  arranged  in  groups 
oil  an  inflamed  base :  these  run  their  course,  and  are  not  usually 
succeeded  by  fresh  groups  of  vesicles  :  there  is  generally  a  feeling 
of  tension  and  burning ;  occasionally  neuralgic  pains  precede  or 
follow  the  eruption.  "  Herpes  labialis"  is  common  in  ordinary 
colds  :  it  also  appears  in  many  cases  of  pneumonia,  and  in  some 
forms  of  urinary  irritation  and  disease.  "  Herpes  prseputialis" 
appears  on  the  prepuce.  "  Herpes  zoster"  (shingles,  zona)  usually 
girdles  the  trunk  unilaterally,  limited  pretty  strictly  by  the  middle 
line,  both  before  and  behind,  but  it  may  affect  the  thigh,  the  face, 
or  an  arm,  following  very  accurately  the  course  of  certain  nerves. 
It  is  not  infectious,  and  rarely  occurs  a  second  time  in  a  patient. 

Eczema  is  now  generally  made  to  include  several  forms  of  skin 
disease  which  were  formerly  separated  from  each  other.  It  is  an 
inflaramatoi-y  disease  with  exudation  and  infiltration  of  the  skin, 
associated  with  a  sense  of  burning  or  itching,  and  it  tends  to  the 
formation  of  crusts.  In  the  ordinary  form  there  are  vesicles  (ec- 
zema vesiculosum)  which  exude  a  clear  fluid,  which  has  the  pro- 
perty of  stiffening  linen ;  an  excoriated  red,  and  inflamed  surface 
usually  remains  exposed  ;  the  discharge  may  dry  very  rapidly  into 
thin  crusts  resembling  scales.  In  some  cases  the  moist  discharge 
may  almost  have  escaped  attention,  redness  and  scaliness  of  the 
skin  being  the  chief  features  (eczema  erythematosum  and  eczema 
squamosum).  In  other  cases  the  plastic  exudation  may  remain 
below  the  surface,  giving  rise  to  little  papules — the  lichen  of  older 
authors,  but  termed  eczema  papulosum  or  lichenoides  by  some.  Or 
the  exudation,  either  from  obvious  irritation,  or  apart  from  this, 
may  become  purulent,  and  the  secretion  of  jjus  may  be  abundant 
from  the  beginning:  this,  which  was  formerly. called  impetigo,  is 
now  often  named  "eczema  pustulosum,"  or  "eczema  impetigi- 
nodes."  Eczema  is  named  from  the  parts  affected,  as  "  E.  auriurn," 
&c.  ;  also  from  obvious  secondary  changes  "  E.  fissum,"  or  from 
the  cause,  as  "  E.  intertrigo"  from  friction. 

Bujna,  see  "ecthyma,"  note,  p.  95 — (although  it  may  begin  as 
a  vesicle  with  clear  fluid,  the  contents  soon  become  bloody  or  puru- 
lent). 

Pemphigus  is  characterized  by  large  blisters,  or  bullae,  varying 
from  the  size  of  a  pea  to  that  of  an  egg,  with  different  degrees  of 
inflammation  at  their  base.  Occasionally  large  thin  crusts  or  scales 
are  formed  ("  P.  foliaceus"). 

Pompholi/x  is  now  merely  a  synonym  for  pemphigus. 


ELEMENTARY    LESIONS.  -95 

Pustidce  may  result  from  the  fluid  in  the  vesicles  becoming 
purulent — this  may  arise  from  irritation  or  other  inflamma- 
tory action ;  the  pus  is  often  formed  so  rapidly  that  it  may 
seem  to  exist  from  the  beginning,  (Willan  and  Bateman 
included  under  "  pustulfe,"  impetigo,  porrigo,  ecthyma,  va- 
riola, scabies.)^ 

Squamae  or  Scales  and  Pityriasis — Scales  must  be  dis- 
tinguished from  thin  crusts  resulting  from  dried  secretion. 
Squamoe  are  scales  from  the  beginning.  When  the  desqua- 
mation is  very  minute  the  term  pityriasis  is  used.  Unfor- 
tunately, however,  a  disease  of  rare  occurrence,  "  pityriasis 
rubra"  is  characterized  by  the  shedding  of  large  scales  or 
flakes.  (Willan  and  Bateman  included  under  "  squamae," 
lepra,  psoriasis,  pityriasis,  ichthyosis.)'^ 

'  Impetigo  is  more  suitably  regarded  as  a  variety  of  eczema  ("  E. 
pustulosum"  or  "  E.  impetiginodes").  For  variola  see  p.  108.  Por- 
rifjo  is  either  an  eczema  or,  it  may  be,  a  parasitic  disease  of  tlie  head 
(see  p.  103). 

Scabies  is  arbitrarily  classed  under  pustulje  ;  it  is,  however,  quite 
as  much  a  papular  or  vesicular  disease  ;  it  is  parasitic,  due  to  the 
presence  of  the  "  acarus  scabiei,"  which  can  often  be  picked  out  as 
a  minute  speck  with  a  needle  from  the  end  of  the  narrow  furrow 
found  between  the  fingers  and  elsewhere.  The  microscope  is  re- 
quired for  the  examination  of  this  insect ;  but  the  furrows  can 
usually  be  recognized.  (See  p.  98,  Fig.  18.) 

Ecthyma  is  the  name  given  when  large  pustules  exist  on  the  skin. 
It  is  often,  if  not  always,  merely  due  to  scabies  or  to  syphilis. 
Syphilitic  pustules  when  large  sometimes  dry  up  into  dark  crusts, 
shaped  like  limpet  shells  :   such  an  eruption  is  termed  "  rupia." 

2  Piti/riasis,  or  desquamation,  occurs  after  erythema,  febrile 
rashes,  and  other  affections  of  the  skin,  so  that  it  often  forms  only 
a  stage  in  a  disease.  "  Pityriasis  versicolor"  is  parasitic,  and  is 
not  properly  a  squamous  disease  (see  Fig.  22,  p.  116).  "  Pityriasis 
rubra  acuta"  is  a  rare  disease  characterized  by  great  redness  of  the 
skin  and  the  shedding  of  large  true  scales,  without  moisture  and 
without  much  infiltration  of  the  skin. 

Psoriasis  and  lepra  (alphos)  are  now  classed  as  one  disease ;  the 
name  "lepra"  was  formerly  applied  to  the  patches  of  this  eruption, 
in  which  it  spread  at  the  circumference  (psoriasis  circinata)  while 
the  centre  was  free  ;  the  form  of  a  ring  was  thus  assumed.  This 
is  a  true  scaly  disease,  without  moist  secretions,  the  scales  are 
white  and  often  glittering,  somewhat  imbricated  and  very  adherent ; 
they  appear  on  dusky  red  patches,  which  are  slightly  elevated  ;  all 
degrees  of  density  in  the  arrangement  of  scales  are  found.  All 
parts  of  the  body  may  be  aff'ected  ;  the  elbows  and  knees  seldom 
escape  in  an  abundant  eruption  of  simple  psoriasis.  When  it  ap- 
pears on  the  palms  of  the  hands,  or  on  the  soles  of  the  feet  alone, 
it  is  almost  invariably  syphilitic.  A  form  of  psoriasis,  resembling 
the  shape  of  rupia  crusts,  has  been  named  "  P.  rupioides." 

Ichthyosis. — When  the  skin  is  dry,  harsh  and  wrinkled,  with  thin 


96  CUTANEOUS    ERUPTIONS. 

TuherciiJa  are  little  lumps,  too  large  to  be  classed  as  pim- 
ples or  dilFering  from  them  in  other  respects.  They  have 
only  an  etymological  connection  with  the  tubercles  recog- 
nized in  the  pathology  of  internal  affections.  They  include 
various  cutaneous  and  mucous  growths  of  perfectly  dissimilar 
kind.' 

(The  various  diseases  formerly  classed  under  this  heading 
are  now  regarded  quite  differently.  They  were :  phyma 
(boil),  verruca  (wart),  molluscum,  vitiligo,  acne,  sycosis, 
lupus,  elephantiasis,  framboesia.) 

Macules  or  Stains  of  the  skin  are  sometimes  hemorrhagic ; 
or  they  may  be  parasitic ;  chemical  agents  and  various  consti- 
tutional disorders  produce  pigmentary  deposits.  (See  p.  115.) 

Secondary  Changes  may  be  present  along  with  various 
forms  of  elementary  lesion. 

Desquamation,  although  often  occurring  independently 
(see  "  Squamte ")  may  form  the  terminal  stage  of  an  ery- 
thema, or  the  like. 

Crusting  is  one  of  the  most  important  secondary  changes. 
Very  thin  crusts  may  resemble  scales,  but  careful  examina- 
tion usually  shows  them  to  be  largely  composed  of  di'ied 
secretions  (in  ichthyosis,  however,  the  scales  are  epithelial). 
The  discharge  may  be  very  slight,  and  may  proceed  from  a 
surface  not  ulcerated,  or  it  may  proceed  from  an  ulcer. 
When  the  crusts  are  dark,  this  usually  points  to  the  pre- 
sence of  a  sanious  fluid  retained  in  them,  and  this  occurs 
frequently  in  syphilis.  Lupus  and  syphilis  differ  in  their 
tendency  to  scabbing — the  ulcers  in  the  former  usually  scab- 
bing slightly,  those  of  the  latter  often  scabbing  freely. 

Cockle-shaped  crusts  are  almost  diagnostic  of  syphilis 
(rupia).  Cup-shaped  crusts  occur  chiefly  in  the  head,  com- 
j)Osed  of  the  parasitic  growth  termed  favus  ;  they  are  light 
yellow  in  color,  and  rather  brittle.     (See  p.  103.) 

scales  loose  at  their  edges,  the  term  "xeroderma"  is  sometimes 
used.  When  the  scales  are  thicker,  more  abundant,  and  mingled 
with  sebaceous  matter,  the  name  "ichthyosis"  is  applied. 

'  Acne,  pimples,  often  becoming  pustules. 

Sycoses  (see  Ringworm  of  Beard,  pp.  101  and  103;. 

Lvpus  is  an  inflammation  and  ulceration  of  the  skin,  occurring  in 
scrofulous  subjects,  and  characterized  by  the  presence  of  a  new 
formation.  When  slight  and  superficial  without  ulceration,  it  is 
called  "lupus  crythematodes."  When  the  deposit  forms  little 
swellings  without  ulceration,  "lupus  non-exedens "  is  the  term. 
When  ulcerations  and  cicatrices  are  present  it  is  called  "lupus 
exegens." 


Anderson's  classification.  -  97 

Ulcerations  are  secondary  changes  which  must  be  ex- 
amined and  described  in  reference  to  their  edges,  &c.,  and 
any  attendant  cachexia,  as  in  surgical  practice. 

Excoriations,  fissures,  scars,  and  atrophic  lesions  are  fre- 
quently very  suggestive,  and  must  be  recorded. 

The  following  indicates  an  attempt  at  a  scientific  classifi- 
cation of  skin  diseases,  so  far  as  this  is  yet  possible.  (Dr. 
A.  B.  Buchanan  slightly  modified  by  Dr.  McCall  Ander- 
son) : — 

A.  Functional  Affections : — 

Pruritus,  seborrhoea,  comedones,  milium,  liyperidrosis,  eplie- 
lis,  melanopathia,  vitiligo,  atrophia  cutis,  alopecia,  liirsuties, 
fragilitas  criiiium. 

B.  Organic  Affections  : — 

I.  Diseases  defined  by  uniform  causes  : — 

(1)  Parasitic  affections — Vegetable — Tinea  favosa,  tinea  tri- 
cophytina  (circinata,  tonsurans,  sycosis),  tinea  versicolor, 
tinea  decalvans.     Animal — Scabies,  phtheiriasis. 

(2)  Syphilitic  affections  : — Primary,  secondary,  and  tertiary 
accidents.     Hereditai-y  syphilis  infantile  and  non-infantile. 

(3)  Strumous  Aifections  : — Lupus,  scrofuloderma,  lichen 
scrofulosorum,  strumous  glands,  ulcers,  and  abscesses. 

(4)  Eruptive  fevers,  Morbilli,  scarlatina,  varicella,  variola, 
typhus,  &c. 

II.  Diseases  not  defined  by  uniform  causes : — 

(1)  Inflammations:  —  Erythema  (stropliulus,  pityriasis, 
rosela),  erythema  nodosum,  eczema  (lichenous,  pruriginous, 
and  impetiginous),  impetigo  contagiosa,  ecthyma  and  non- 
syphilitic  rupia,  prurigo,  urticaria,  zona,  dermatitis,  erysipe- 
las, acne,  psoriasis  (or  lepra),  pemi^liigus,  pityriasis  rubra. 
Deep  inflammations  (furunculus). — Ulcers  (independent  of 
struma  and  syphilis),  onychia. 

(2)  New  Formations  : — Varix,  njevus,  verruca,  callositas, 
clavus,  cornu,  ichthyosis,  scleroderma,  elephantiasis  Arabum, 
E.  Grfecorum,  molluscum  contagiosum,  fibroma  molluscum, 
cicatrix,  cheloid,  cysts,  scirrhus  epithelioma,  tumors  of  other 
kinds. 

(3)  Hemorrhages.     Purpura. 

Distribution  of  Eruptions — In  examining  a  cutaneous 
eruption,  it  is  a  great  advantage  to  see  the  surface  of  the  whole 
body,  or  as  much  of  it  as  possible.  Special  abundance  of  it  on 
certain  parts,  or  the  special  exemption  of  others,  affords  at 
times  considerable  assistance  in  the  diagnosis.  We  can  in 
this  way  also  detect  the  symmetrical  character  of  many  erup- 
tions, or  the  essential  local  disposition  of  others — as  when 
the  hand  is  affected  by  some  irritant  encountered  in  a  trade, 
or  when  the  eruption  is  caused  by  stockings  with  analine  or 
9 


98 


CUTANEOUS    ERUPTIONS. 


arsenical  dyes.  Some  eruptions,  again,  follow  the  course  of 
certain  nerves,  and  in  zona  we  have  usually  a  pretty  strict 
limitation  to  one-half  of  the  body,  the  eruption  stopping  at 
the  middle  line  both  before  and  behind  when  the  trunk  is 
involved.  But  in  addition  to  the  general  view  of  the  sur- 
face, special  regions  must  be  examined  for  special  eruptions. 
Of  the  febrile  rashes,  some  show  lii'st  on  the  face  (variola 
and  morbilli),  but  most  of  them  appear  first  on  the  trunk,  so 
that  we  much  search  the  chest,  abdomen,  and  back,  and  we 
should   also  examine  the  arms  at  the  anterior  aspect  of  the 


-The  itch  insect.  Acarus  Scabiei.     Female  ;  ventral  aspect. 
(Drawn  by  Dr.  John  Wilson.) 


elbows,  (fee,  where  the  skin  is  delicate.  We  look  at  the 
elbows  and  knees  particularly  in  psoriasis ;  at  the  chest  and 
back  in  syphilis ;  at  the  clefts  of  the  fingers  in  scabies,  to 
see  if  any  little  furrows  are  present,  and  also  at  the  inside  of 
the  thighs,  the  w^'ists,  ankles,  and  umbilicus  in  this  affection  ; 
between  the  shoulders  in  phtheiriasis  ;  over  the  chest  in 
pityriasis  vei'sicolor ;  on  the  head  in  ringworm  and  favus ; 


ITCHING.  99 

over  the  shins  in  erythema  nodosum ;  on  the  face  and 
shoulders  in  aene,  etc. 

The  constitutional  disturhance  and  the  general  symptoms 
associated  with  cutaneous  eruptions  must  be  cai'efuUy  in- 
quired into.  Pyrexia,  headache,  and  perhaps  delirium,  pain 
in  the  back,  sickness,  vomiting  or  shiverings ;  and  pain, 
burning,  tingling,  and  itching  in  the  parts  aiiected  are  the 
most  important.  Intense  pyrexia  often  precedes  the  appear- 
ance of  the  rash  in  the  eruptive  fevers  and  erysipelas,  and 
(as  mentioned  in  the  section  on  Pyrexia),  the  skin  must 
then  be  carefully  examined  by  good  daylight,  if  possible,  for 
any  appearance  of  a  rash.  The  inspection  of  the  skin  for  a 
febrile  rash  should,  in  the  first  instance,  be  made  at  such  a 
distance  (2  to  5  feet)  that  the  general  appearance  of  the 
surface  can  be  seen,  rather  than  the  minute  alterations  in 
the  skin ;  these  may  be  subsequently  examined  if  necessary. 
Pain  in  the  back  and  vomiting  are  specially  suggestive  of 
smallpox ;  intense  headache  of  typhus ;  sore  throat  and 
vomiting  of  scarlatina ;  coryza  and  catarrh  of  measles ;  sliiv- 
erings  may  occur  in  tlie  early  stage  of  any  of  these,  and  also 
in  erysipelas.  But  even  in  those  forms  of  eruptions,  more 
usually  called  diseases  of  the  skin,  there  may  be  much  con- 
stitutional disturbance,  with  considerable  pyrexia  and  some 
gastric  disorder,  as  in  eczema  and  urticaria.  The  intensity 
of  the  genei'al  symptoms  bears  a  much  more  distinct  relation 
to  the  extent  of  the  cutaneous  affection  in  these  cases  than 
in  the  eruptive  fevers.  Severe  neuralgic  pains  sometimes 
precede,  sometimes  follow,  the  eruption  of  herpes  zoster. 
Considerable  pain  is  often  experienced  in  eczema,  but  in 
such  a  case  the  cause  is  apparent. 

Itching  is  an  important  fact  in  cutaneous  disease.  It  is 
seldom  very  troublesome  in  the  eruptive  fevers,  although 
often  present  in  measles,  smallpox,  and  chicken-pox.  It  is 
seldom  marked  in  syphilitic  eruptions,  so  that  its  absence 
counts  for  something  in  the  diagnosis.  In  urticaria,  psoriasis, 
and  eczema,  itching  is  often  very  troublesome.  In  parasitic 
diseases  it  is  a  very  prominent  feature,  especially  in  scabies 
and  phtheiriasis.  The  existence  of  itching  can  usually  be 
recognized  by  the  presence  of  a  "  pruriginous  eruption"  due 
to  scratching,  and  the  marks  of  the  nails  often  tell  the  same 
story ;  this  irritation  alters  the  appearance  of  an  eruption 
very  materially,  chiefly  by  causing  inflammation.  Itching, 
however,  may  exist  without  any  eruption.  In  some  of  these 
cases,  this  may  be  due  to  a,  nervous  aflfection  of  the  skin,  the 


100  CUTANEOUS    ERUPTIONS. 

priu'itus  varying  much  at  particular  times.  Pruritus,  espe- 
cially at  the  intestinal  and  genito-urinaiy  orifices,  may  be 
symptomatic  of  disease  of  the  womb,  stone  in  tlie  bladder, 
diabetes,  piles,  or  other  affections  of  the  rectum.  In  many 
cases,  especially  (although  not  exclusively)  in  cliildren,  itch- 
ing at  the  anus  is  due  to  the  presence  of  thread  worms  ;  in 
them  it  is  often  associated  with  itching  at  the  nose  also,  as 
manifested  by  picking  at  the  nostrils.  But  this  picking 
occurs  also  in  diarrhoea  and  other  forms  of  intestinal  irri- 
tation. 

Itching  is  occasionally  present  to  a  troublesome  extent  in 
jaundice ;  it  is  not  unfrequently  produced  by  the  internal  use 
of  opium  and  morphia  in  all  their  forms.  Some  persons  are 
especially  liable  to  this  inconvenience  in  the  use  of  opium. 
An  itching  of  the  eyelids  is  one  of  the  indications  of  the 
action  of  arsenic. 

Causes  of  Cutaneous  Eruptions.  Infection,  Medi- 
cine, Food.  In  inquiring  as  to  the  cause  of  eruptions,  we 
may  ascertain  the  patient's  ideas  on  the  subject,  or  we  may 
interrogate  him  as  to  special  points  in  connection  with  spe- 
cial forms  of  disease. 

Infection In  the  group  of  eruptive  fevers  we  inquire  for 

any  similar  illnesses  in  the  same  family  or  neighborhood. 
Some  assistance  is  at  times  obtained  by  learning  that  the 
patient  has  formerly  had  certain  specific  fevers,  as  a  second 
attack  in  some  of  these  is  but  rarely  met  with.  (See  p.  106.) 
In  suspected  erysipelas,  we  inquire  for  exposure  to  this  dis- 
ease in  surgical  wards,  or  otherwise  ;  and  for  any  contact 
with  puei-peral  fever  or  pya;mia,  especially  if  our  patients  are 
predisposed  to  infection  by  open  sores,  &c.  In  children,  and 
especially  in  hospital  practice,  where  infection  may  be  pre- 
sent, wounds  or  open  sores  predispose,  apparently,  to  the 
occurrence  of  scarlatina,  which  may  be  mistaken  for  ery- 
thema or  erysipelas.  In  syphilitic  eruptions  we  may  inquire 
for  the  history  of  the  original  infection  in  the  patient,  or  in 
the  parents,  and  in  the  brothers  and  sisters  in  the  case  of  con- 
genital syphilis ;  in  this  last  variety,  the  occurrence  of  abor- 
tions before  the  birth  of  the  patient  is  often  an  important 
indication  of  syphilis.  But  in  addition  to  cases  of  this  kind, 
we  can  sometimes  trace  the  infection  of  a  patient  from 
secondary  or  congenital  syphilis.  A  nurse's  arm  may  be 
infected  from  the  sores  on  an  infant's  anus,  or  the  nipple  from 
the  sores  on  the  child's  mouth,  or  vice  versa.  In  impetigo 
contagiosa  the  patient  may  inoculate  one  part  from  another 


PARASITIC    DISEASES.  101 

by  means  of  scratching.  The  occupation  is  important  in 
connection  with  cases  of  suspected  glanders,  malignant  pus- 
tule, &c. 

In  parasitic  diseases  we  often  gain  considerable  assistance 
from  the  knowledge  of  their  having  spread  by  infection. 
Thus,  if  two  persons  sleep  in  the  same  bed,  scabies  is  almost 
certain  to  be  communicated  from  the  one  to  the  other.  This 
disease  is  often  communicated  by  infected  bed-clothes,  apart 
from  any  direct  contact  with  patients  so  affected.  In  ring- 
worm the  affection  often  spreads  from  the  use  of  the  same 
hair-brushes,  although  the  patients  may  not  otherwise  be 
much  associated  ;  ringworm  of  the  body  may  appear  in  those 
who  are  attending  on  children  affected  with  it  on  the  head. 
In  favus  the  contagion  may  be  derived  from  some  pet  animal 


Fig.  19. — Pedieulus  pubix,  or  Crab  Louse,  witli  ova  adlieriug  to  tbe  hair. 
(Drawu  bv  Dr.  John  Wilson.) 

as  well  as  from  a  patient.  The  pediculus  pubis  is  sometimes 
found  in  persons  of  good  position  from  their  consorting  with 
pi-ostitutes.  The  itch  insects,  and  pediculi  corporis  often 
continue  to  act  on  the  patient  through  the  medium  of  the 
underclothing  and  the  bed-clothes,  even  after  those  on  the 
skin  have  been  got  rid  of.  Certain  varieties  of  the  same 
parasitic  disease  must  be  borne  in  mind  while  searching  for 
the  history  of  infection — thus  we  have  ringworm  of  the  head, 
of  the  body,  and  of  the  beard. 

Certain  medicines  and  articles  of  diet  are  apt  to  produce 
cutaneous  eruptions.  Shell-fish,  preserved  salmon,  cucum- 
bers, walnuts,  game,  and  various  other  things  produce  at 
times  an  eruption  of  urticaria  or  erythema.  Some  persons, 
indeed,  are  particularly  liable  to  this  effect  from  special  arti- 

9* 


102  CUTANEOUS    ERUPTIONS. 

cles,  so  that  it  is  almost  certain  to  follow  their  use  ;  in  others, 
the  effect  is  less  certain.  These  eruptions  sometimes  simu- 
late the  specific  fevers  ;  the  absence  of  constitutional  disturb- 
ance in  proportion  to  the  rasli,  and  the  absence  of  the  special 
features  of  the  specific  fever  simulated  may  sometimes  guide 
us  in  the  discrimination.  Of  medicines,  iodide  and  bromide 
of  potassium,  belladonna  and  atropine,  sulphur,  arsenic,  tar, 
and  copaiba  may  be  named  as  all  producing  at  times  cutane- 
ous eruptions. 

Iodide  and  bromide  of  potassium  produce  pimples  (acne) 
Avhich  appear  chiefiy  on  the  face  and  shoulders  :  occasionally 
the  eruption  is  more  distinctly  pustular.  The  aftection  of  the 
mucous  membrane  of  the  nose  and  eyes  and  the  swelling  of 
the  glands  behind  the  jaws,  sometimes  guide  us  in  the  recog- 
nition of  iodism. 

Belladonna  and  atropine  produce  at  times  a  distinct  ery- 
thema somewhat  resembling  that  of  scarlatina ;  a  certain 
similarity  to  the  eruption  of  measles  is  found  in  some  cases. 
This  rash  may  result  from  the  internal  use  of  the  drug 
(usually  in  full  doses),  or  from  the  action  of  external  appli- 
cations in  the  form  of  plasters,  especially  if  excoriations 
exist  on  the  skin.  Dryness  of  the  fauces  and  more  or  less 
dilatation  of  the  pupils  are  usually  present  to  assist  in  the 
recognition  of  this  eruption. 

Arsenic  produces,  although  but  rarely,  an  eruption  some- 
what resembling  eczema,  or  at  least  a  prominence  of  the 
papilla?  with  congestion  of  the  skin.  In  certain  cases  herpes 
zoster  has  appeared  to  be  due  to  the  use  of  arsenic,  and  pity- 
riasis rubra  has  also  been  known  to  supervene  in  connection 
with  its  administration.  Puffiness  and  itching  of  the  eyelids, 
sickness  or  pains  in  the  bowels,  and  whiteness  of  the  tongue 
assist  in  the  recognition  of  arsenical  influence.  Local  irri- 
tation from  arsenic  may  manifest  itself  by  ulcei'ations  of  the 
part  affected. 

Sulphur  and  tar  are  said  to  produce  at  times  an  eruption 
resembling  a  badly. developed  eczema. 

Copaiba  gives  rise  in  some  cases  to  urticaria  of  the  usual 
kind,  but  the  white  parts  of  the  wheals  may  be  absent,  so 
that  the  rash  is  only  red  ;  at  times  this  eruption  closely  simu- 
lates measles  in  its  general  appearance,  but  it  does  not 
specially  affect  the  face  and  is  not  associated  with  catarrh. 
Copaiba  is  so  much  used  in  the  treatment  of  gonorrhoea  that 
when  we   see  an   eruption  associated  with   this  disease  we 


AFFECTIONS    OF    THE    HAIR.  103 

should  always  suspect  the  action  of  this  drug.  Nitrate  of 
silver  administered  internally  may  cause  a  dark  discoloration 
of  the  skin  affecting  the  parts  exposed  to  the  light. 

In  addition  to  the  above  a  great  many  remedies  produce 
eruptions  from  their  local  action  if  applied  to  the  skin. 

Affections  of  the  Haik;  Examination  of  Vegeta- 
ble Parasites Absence  of  the  hair  is  termed  "  alopecia." 

This  is  sometimes,  although  very  rarely,  almost  universal, 
affecting  even  the  minute  hairs  in  every  part  of  the  body 
(alopecia  universalis).  The  baldness  of  advancing  years, 
and  premature  baldness,  which  is  often  hereditary,  need  only 
be  mentioned.  The  loss  of  the  hair  in  syphilis,  and  after 
fevers  and  erysipelas,  is  usually  only  temporary,  but  some- 
times a  partial  baldness  becomes  permanent  in  this  way. 
Limited  patches  of  baldness  on  the  scalp,  and  more  rarely 
of  the  beard,  assuming  a  circular  form,  or  at  least  with  cir- 
cular margins,  are  termed  "  alopecia  areata  ;"  in  this  affection  " 
the  hair  is  quite  absent  in  the  fully  developed  affection,  the 
skin  being  quite  smooth  and  even  glossy.  It  is  supposed  by 
some  to  be  due  to  a  parasite  (Microsporon  Audouini),  by 
others  it  is  regarded  as  a  neurosis.  In  ring-worm  and  favus 
the  hairs  are  not  quite  absent,  the  bald  patches  present  some 
stunted  hairs.  In  favus  the  hairs  are  found,  in  a  typical 
case,  to  pierce  a  cup-shaped  yellow  crust  near  its  centre  ;  this 
sulphur-colored  crust  frequently  has  a  mouse-like  odor ; 
patches  of  red,  irritable,  shining  skin  may  be  found  where 
the  hair  follicles  have  been  destroyed. 

In  ring-worm  the  hairs  resemble  stubble,  being  dry  and 
withered ;  the  brittle  hairs  break  off  short ;  there  is  often 
fine  white  dust  at  their  bases,  and  the  skin  between  them 
presents  an  appearance  like  that  of  a  plucked  fowl. 

In  examining  hairs,  scales,  &c.,  for  vegetable  parasites 
certain  precautions  should  be  used.  A  diseased  hair  should, 
of  course,  be  selected  if  possible  for  the  examination ;  we 
judge  by  its  stunted,  brittle  appearance,  and  by  its  looseness 
on  extraction.  In  examining  scales,  too  much  of  them  may 
render  the  specimen  rather  opaque ;  the  scales  and  even  the 
hairs  may  have  to  be  dissected  by  needles  to  expose  the  par- 
asitic growths.  Digestion  in  a  solution  of  caustic  potash 
renders  the  specimen  more  transparent.  In  certain  cases  it 
is  very  desirable  to  get  I'id  of  the  fat  about  the  hair  or  the 
scales,  as  the  small  oil  globules  simulate  vegetable  spores. 
To  remove  these  sulphuric  ether  may  be  used,  either  before 


104 


CUTANEOUS    ERUPTIONS. 


the  application  of  the  potash  or  after  it,  the  specimen  being 
dried  from  the  one  before  the  other  is  applied. 

In  examining  for  vegetable  parasites,  we  search  for  spores 
(conidia)  ;  these  are  small  globular  bodies,  usually  arranged 
in  groups  or  clusters,  or  in  rows  ;  Avhen  rows  of  these  exist 
tjiey  may  give  off  branches  (sporidia).  Branching  tubes, 
often  of  a  very  fine  thread-like  structure,  constitute  the 
"  mj'celium"  or  "  thallus"  of  these  vegetable  growths  ;  they 
vary  much  in  diameter,  and  often  interlace  in  the  most  intri- 
cate manner.  These  growths  are  not  destroyed  by  caustic 
potash,    alcohol,    ether,  or    chloroform ;    in   doubtful    cases, 


Fig.  20. — Portion  of  liair  fiom  a  case  of 
Favus — Tinea  Favosa — showing  spores  of 
vegetable  parasitic  growtli  —  Achorion 
Schunleinii.     (Reduced  from  Bazin.) 


t 


Fig.  21. — Portion  of  hair  from 
a  case  of  Ringworm  —  Tinea 
Tonsurans,  or  Tinea  Tricophy- 
tina — showing  vegetable  para- 
sitic growth  (with  sporules  in- 
filtrating  hair,  and  a  fragment  of 
a  tubular  growth) — the  Tricc- 
phyton  tonsurans.  (Reduced 
from  Baziu.) 


where  fat,  blood,  or  j)us  may  simulate  spores,  these  re-agents 
may  be  absolutely  required  for  the  discrimination.  Foreign 
bodies  containing  vegetable  fibres  may  sometimes  simulate 
mycelium,  but  care  in  selecting  the  specimen  and  the  ab- 
sence of  branching  usually  prevent  error. 


FEBRILE    RASHES.  105 


FEBRILE  RASHES. 

Certain  specific  febrile  diseases  are  characterized  by  the 
appearance  of  a  cutaneous  eruption.  They  are  typhus, 
enteric,  and  scarlet  fever,  measles,  smallpox,  and  chicken- 
pox  ;  erysipelas  may  also  be  included  in  this  list  for  our  pre- 
sent purpose.  In  addition  to  these,  cutaneous  eruptions  are 
occasionally  seen  in  relapsing  fever  and  in  diphtheria ;  some 
have  alleged  the  occasional  presence  of  an  eruption  in  pneu- 
monia and  acute  tuberculosis,  but  this  must  still  be  reckoned 
doubtful.  In  all  of  these  diseases  the  eruption  is  preceded 
by  constitutional  disturbance  and  the  general  signs  of  fever, 
especially  by  pyrexia,  shiverings,  sickness,  and  vomiting, 
headache,  pain  in  the  back,  and  general  malaise,  delirium, 
and  great  nervous  disturbance ;  convulsions  are  often  met 
with  in  children.  Certain  of  these  symptoms  are  more  pro- 
nounced in  some  fevers  than  in  others,  and  several  of  them 
may  be  almost  absent  in  certain  cases.  In  addition  to  those 
which  may  be  regarded  as  common  to  all,  special  symptoms 
are  found  in  special  fevers,  as  the  sore  throat  of  scarlatina 
and  diphtheria,  the  catarrh  and  coryza  of  measles,  and  the 
diarrhoea  of  enteric  fever.  The  history  of  infection  and  of 
previous  attacks  of  special  fevers  sometimes  guides  our  diag- 
nosis. The  date  at  which  the  rash  appears,  or  its  absence  at 
a  given  time,  constitutes  an  important  element  in  the  differ- 
ential diagnosis.  But  in  considering  the  following  dates 
some  allowance  must  be  made  for  uncertainty  in  fixing  the 
correct  date  of  the  illness ;  for  a  slight  variation  from  the 
average  date  of  the  eruption  ;  and  also  for  the  occasional 
delay  of  the  eruption  quite  beyond  its  usual  term,  or  even 
for  its  non-appearance,  its  suppression,  or  its  fugitive  cha- 
racter (especially  in  malignant  scarlatina). 

Subject  to  these  qualifications,  which  are  indicated  more! 
fully  in  the  remarks  on  the  eruptions  in  detail,  the  following 
dates  may  be  given  : — 

DATE  OF  APPEARANCE  OF  THE  FEBRILE  RASHES 
AFTER  THE  FIRST  SIGNS  OF  ILLNESS. 

Scarlatina  Rash  appears  on  the  first  or  second  day. 

Smallpox  appears  on  the  third  day. 

Measles  appears  on  the  fourth  day. 

Typhus  appears  on  the  fifth  day. 

Enteric  Fever  appears  on  the  seventh  day  or  later. 


106  CUTANEOUS    ERUPTIONS. 

Chichen-pox  usually  shows  itself  within  the  first  clay  after 
the  constitutional  disturbance,  but  this  is  often  so  slight  as 
not  to  be  clearly  marked. 

German  Measles  (Red  Measles,  Eotheln,  Roseola,  &c.) 
may  appear  on  the  second,  third,  or  fourth  day,  or  the  rash 
may  be  amongst  the  very  first  symptoms. 

Erysipelas  varies  considerably  as  to  the  date  of  its  appear- 
ance on  the  skin,  but  may  usually  be  detected  on  the  day 
after  shiverings  or  other  febrile  disturbances  have  appeared. 
Occasionally,  however,  the  rash  is  delayed  or  suppressed,  or 
appears  only  as  fugitive  patches  which  readily  escape  notice, 
just  as  happens  in  certain  cases  of  scarlatina. 

PERIOD  OF  INCUBA  TION. 

This  is  not  always  uniform,  and  in  many  cases  cannot  be 
determined  with  accuracy,  as  the  infection  may  linger  in  the 
clothing  or  other  materials  (fomites),  after  the  direct  expo- 
sure of  the  person  to  the  disease. 

Scarlatina :  incubation  period  varies  from  a  day  to  eight  or  ten 
days  :  apparent  j^rolongation  for  a  longer  period  (which  is  not 
unusual)  can  often  be  explained  more  naturally  on  the  sup- 
position of  infection  through  clothing  and  the  like. 

Smallpox:  thirteen  or  fourteen  days. 

Varicella,  or  Chicken-pox :  ten  to  fourteen  days. 

Measles:  usually  about  a  fortnight ;  said  to  be  seven  days  when 
inoculated  from  nasal  mucus  ;  variation  in  extreme  form  seven 
to  twenty -one  days. 

German  measles  (Rotheln)  :  varies  from  seven  to  fourteen  days. 

Typhus  fever :  varies  from  a  single  day  to  nearly  three  weeks  ; 
usually  about  seven  to  fourteen  days. 

Enteric  fever ;  about  two  or  three  weeks. 

Erysipelas :  period  very  uncertain  ;  probably  short,  as  a  rule. 

LIABILITY  TO  SECOND  ATTACKS. 

Scarlatina :  an  indubitable  second  attack  very  rare,  but  not 
unknown ;  dubious  illness  sometimes  called  scarlet  fever  may 
account  for  most  of  the  so-called  second  attacks. 

Varicella  or  Chicken-pox :  a  second  attack  extremely  rare. 

Typhus  fever  :  a  second  attack  extremely  rare,  biit  not  unknown  ; 
the  common  confusion  between  tyjjhus  and  typhoid  (enteric) 
fever  must  be  remembered  in  judging  the  history  of  patients. 

Smallpox :  a  second  attack  apparently  not  very  uncommon ;  errors 
in  the  diagnosis  from  other  forms  of  pustular  eruptions  are 
quite  possible.  Traces  of  former  attacks  are  usuall}^  quite 
visible. 

Measles:  a  second  attack,  as  alleged,  is  very  common;  possibly 


SCARLATINA    RASH.  lOt 

this  may  arise  from  there  being  two  forms  of  measles  with  dis- 
tinct powers  of  infection  (see  Rcitheln  or  German  measles). 

Enteric  fever :  one  attack  does  not  seem  to  protect  from  a  second 
(relapses  are  also  very  common). 

Erysipelas :  one  attack  seems  rather  to  predispose  to  a  second 
than  to  afford  exemption. 

The  Scarlatina  rash,  when  well  developed,  presents  a 
bright  uniform  redness  very  similar  to  that  of  a  boiled  lob- 
ster. In  the  early  stage  a  multitude  of  minute  red  points 
can  often  be  recognized,  but  these  soon  coalesce  and  present 
an  uniform  redness.  The  rash  usually  appears  first  on  the 
chest,  abdomen,  neck,  or  back.  It  sometimes  comes  out  first 
on  the  legs.  It  disappears  on  pressure — pressure  with  the 
fingers,  or  strokes  with  the  nails  leaving  white  marks.  In 
the  progress  of  the  rash  it  extends  from  the  trunk  to  the  arms 
and  legs,  and  fi-equently  can  be  seen  to  have,  as  it  were, 
fresh  developments,  fading  in  one  part  while  extending  to 
others,  and  varying  in  brightness  at  ditf'erent  times.  Towards 
the  end  of  the  first  week  it  usually  begins  to  fade,  and  disap- 
pears as  a  rule  before  the  tenth  or  twelfth  day.  After  the 
rash  fades  desquamation  begins,  and  this  is  usually  in  pro- 
portion to  the  severity  of  the  rash.  (Desquamation,  arthritic 
pains,  and  albuminous  urine  often  point  to  the  scarlatinal 
nature  of  a  rash  previously  regarded  as  trifling.)  At  times 
the  scarlatina  rash  is  so  faint  and  evanescent  as  to  be  diffi- 
cult of  recognition.  Examination  by  good  daylight  is  very 
important  in  such  cases.  In  malignant  forms  the  rash  is 
sometimes  very  dusky  or  almost  petechial ;  in  other  cases  it 
is  patchy  and  shifting  in  its  appearance.  In  the  puerperal 
form  the  rash  may  not  be  noticeable,  or  may  only  be  trace- 
able as  slight  patches  on  the  hands  or  elsewhere. 

The  rashes  most  likely  to  be  mistaken  for  scarlatina  are 
the  belladonna  rash,  the  eruption  of  urticaria  when  the  white 
parts  of  the  wheals  are  absent,  and  some  forms  of  erythema. 
This  last  disease  has  probably  sometimes  been  the  real  affec- 
tion in  patients  said  to  have  been  repeatedly  attacked  by 
scarlatina.  In  young  infants  a  transient  erythema  or  roseola 
simulates  scarlatina :  its  repetition  and  the  absence  of  sore 
throat  serve  to  guide  us.  In  German  measles,  the  rash  often 
resembles  scarlatina  so  closely  that  it  cannot  be  discriminated 
in  the  later  stage  of  the  eruption.  In  all  cases  of  doubtful 
rash,  the  character  of  the  tongue,  and  especially  the  presence 
of  sore  throat,  with  patches  on  the  tonsils  or  ulcerations,  con- 
stitute  most  important  guides ;   indeed,  when   the  rash   is 


108  CUTANEOUS    ERUPTIONS. 

copious  we  must  have  great  hesitation  in  admitting  its  scar- 
hitinal  nature  if  there  be  no  sore  throat.  Constitutional  dis- 
turbance and  pyrexia  are  present  in  all  degrees  in  scarlatina, 
and  sometimes  are  so  slight  as  to  evade  our  recognition. 
Subsequent  desquamation  or  peeling  of  the  skin  about  the 
fingers  or  elsewhere,  and  the  occurrence  of  albuminuria  about 
the  tenth  to  the  twentieth  day  often  clear  up  the  nature  of  a 
doubtful  rash.  A  previous  attack  of  scarlatina  is  not  an 
absolute  protection  from  this  disease,  but  it  is  rare  to  find 
clear  evidence  of  a  second  attack. 

An  eruption  of  roseola,  somewhat  resembling  that  of  scar- 
latina, sometimes  appears  before  the  smallpox  rash  comes 
out.  It  is  likewise  found  after  vaccination,  and  revaccina- 
tion.  A  similar  redness  is  noticed  occasionally  in  enteric 
fever  in  its  early  stage,  and  in  connection  with  relapses. 
(Roseola  exanthematica.) 

The  Smallpox  eruption  (Variola)  appears  as  a  rule  on  the 
third  day,  but  sometimes  on  the  second,  fourth,  or  fifth.  In 
serious  cases  it  appears  early  as  a  rule.  The  stage  of  incu- 
bation is  usually  a  fortnight.  Occasionally  a  "  roseola" 
precedes  the  true  smallpox  eruption,  giving  rise  to  the  idea 
of  scarlatina.  The  appearance  of  the  smallpox  rash  is  usu- 
ually  associated  with  a  distinct,  and  (5ften  with  a  very  great 
diminution  of  the  previous  febrile  disturbance,  unless,  indeed, 
in  the  graver  forms,  where  the  decline  may  be  scarcely 
noticeable.  The  eruption  appears  first  on  the  face  and  neck 
in  most  cases,  but  sometimes  on  the  palate,  the  wrists,  or 
the  trunk  ;  it  spreads  to  the  other  part  in  a  day  or  two.  At 
the  beginning  the  eruption  consists  of  red  papules  ;  these 
can  be  felt  to  be  hard,  like  small  shot  embedded  under  the 
skin.  The  pimples  in  the  course  of  a  day  or  two  become 
vesicular,  but  the  contents  rapidly  become  purulent,  and  an 
area  of  inflammation  (areola)  appears  around  the  pustules ; 
considerable  swelling  and  itching  of  the  skin  usually  accom- 
pany a  severe  eruption.  When  the  pustules  run  into  one 
another  they  are  called  "  confluent,"  when  they  remain 
quite  separate  the  term  "  discrete"  is  applied.  A  depression 
in  the  centre  of  the  pustule  usually  becomes  apparent  soon 
after  it  is  formed,  but  this  "  umbilication,"  as  it  is  called, 
does  not  always  occur,  and  sometimes  it  becomes  efifaced. 
Each  pustule  is  multilocular.  The  "  maturation"  of  the 
pustule  occurs  about  the  ninth  day.  As  the  pustules  shrink 
scabs  are  formed,  and  when  these  separate  dark-colored 
stains  remain  for  a  time.     Depressed  marks  or  "  pits"  are 


i 


CHICKEN-POX  109' 

left  in  proportion  to  the  severity  of  the  case.  The  snaallpox 
papules  may  often  be  felt  in  the  roof  of  the  mouth,  the  soft 
palate,  and  the  tongue ;  the  eruption  occurs,  also,  in  other 
parts  of  the  mucous  surface.  In  severe  cases  hemorrhages 
are  seen  under  the  skin  as  well  as  inside  the  pustules.  Hem- 
orrhages from  the  mucous  membranes  and  a  few  papules 
may  be  the  only  manifestation  of  hemorrhagic  smallpox. 

In  smallpox  modified  by  vaccination,  the  eruption  is  usu- 
ally less  abundant  and  is  not  often  confluent.  The  constitu- 
tional disturbance  may  be  considerable  or  but  slight.  The 
eruption  may  closely  resemble  that  of  unmodified  smallpox, 
or  it  may  consist  simply  of  a  few  abortive  pimples  without 
any  pi'oper  vesication  or  pustulation.  Vaccination  and  re- 
vaccination  lessen  the  chance  of  contracting  smallpox  very 
materially. 

Ghichen-pox  (Varicella)  resembles  smallpox  in  many  re- 
spects, but  it  is  essentially  vesicular,  although  it  may  be 
pustular  where  irritated  ;  the  hard  nodular  papules  are  usu- 
ally absent.  The  eruption  has  no  special  preference  for  the 
face  but  rather  for  the  shoulders,  back,  and  hairy  scalp.  The 
vesicles  are  preceded  by  an  eruption  of  red  spots,  but  slightly 
elevated  :  the  lesion  is  altogether  much  more  superficial  than 
in  smallpox  and  there  are  no  dissepiments  in  the  vesicles. 
The  eruption  usually  appears  within  twenty-four  hours  of 
the  preceding  disturbance,  if  there  has  been  any,  but  as  a 
rule  this  is  slight.  A  succession  of  separate  crops  of  the 
eruption  can  often  be  recognized  from  their  being  present  in 
different  stages.  It  is  an  infectious  disease,  but  usually 
attacks  children  only.  It  is  not  prevented  by  vaccination, 
and  does  not  protect  the  patiant  from  smallpox. 

The  chief  difficulties  in  the  diagnosis  of  smallpox  arise  in 
the  slighter  forms,  occurring  in  vaccinated  persons,  as  the 
few  pimples  which  appear  may  be  regarded  as  trivial,  espe- 
cially if  the  patient  be  subject  to  acne.  In  some  forms  of 
measles  a  certain  resemblance  to  smallpox  arises  from  the 
papules  in  the  early  stage  being  usually  hard,  or  from  the 
dusky  hue  and  hemorrhagic  tendency  of  the  rash.  In  some 
forms  of  smallpox  also,  the  rash  resembles  measles  from  a 
transient  efliorescence  forming  a  basis  for  a  subsequent  pajiu- 
lar  eruption.  The  presence  or  absence  of  the  shot-like 
papules  peculiar  to  smallpox  and  the  subsequent  course 
usually  guide  us  aright.  A  pustular  eruption  in  syphilis 
sometimes  resembles  smallpox  very  closely,  especially  when 
it  appears  after  great  general  disturbance.  An  eruption 
10 


110  CUTANEOUS    ERUPTIONS. 

from  iodide  of  potassium,  usually  papular  but  sometimes 
pustular,  occasionally  simulates  smallpox.  The  presence  of 
the  loculi  and  the  umbilication  in  smallpox  pustules  are  often 
useful  in  guiding  us. 

Chicken-pox  and  smallpox,  although  usually  differentiated 
easily  enough,  are  sometimes  quite  undistinguishable  in  the 
modified  form  of  the  disease,  at  least  in  isolated  cases. 

The  Measles  eruption  appears  usually  on  the  fourth  day, 
and  corresponds  with  an  exacerbation  of  the  prodromal  fever. 
It  appears  almost  always  on  the  face  first.  It  consists  of 
elevated  red  spots  or  patches,  which  tend  to  assume  a  circular 
or  crescentic  outline.  At  first  the  skin  between  the  spots  is 
not  red,  but  it  usually  becomes  so  in  some  parts,  and  the 
elevated  patches  often  coalesce.  The  eruption  spreads  from 
the  face  to  the  trunk,  and  from  the  trunk  to  the  limbs.  It 
may  be  three  or  four  days  before  the  rash  attains  its  maxi- 
mum extent,  and  it  may  be  fading  in  some  parts  as  others 
become  affected.  The  rash  fades  on  pressure  in  ordinary 
cases,  but  in  grave  forms  the  eruption  may  be  dusky  and 
even  petechial.  Considerable  swelling  of  the  skin  of  the 
face  is  usually  obvious  in  measles.  The  coincident  pheno- 
mena generally  guide  us  aright  in  the  early  stage  or  in 
doubtful  cases ;  running  at  the  nose  and  eyes,  sneezing,  cough, 
and  bronchitic  rales  are  very  common.  In  cases  with  a  re- 
ceding or  undeveloped  rash  w'e  have,  at  times,  grave  nervous 
disturbance. 

The  eruptions  most  likely  to  be  confounded  with  measles 
are  copaiba  rash  (see  p.  102),  typhus,  roseola,  and  hemor- 
'rhagic  smallpox  in  the  early  stage. 

The  German  Measles  rash  (rubeola  notha,  roseola,  rotheln, 
rosalia)  resembles  at  times  measles  and  at  times  scarlatina, 
or  it  may  begin  with  a  resemblance  to  measles  and  become 
.  very  like  scarlatina.  It  does  not  show  such  a  preference  for 
the  face  as  measles,  and  the  crescentic  character  is  less 
marked.  The  rash  may  be  very  abundant  with  but  a  mode- 
rate temperature  (102°  or  103°  F.).  It  usually  appears 
about  the  same  time  after  the  beginning  of  the  febrile  dis- 
turbance as  a  scarlatina  rash,  but  may  be  somewhat  later. 
There  may  be  slight  sore  throat,  but  seldom  any  ulceration. 
There  maybe  slight  bronchial  catarrh.  The  symptoms,  like 
the  rash,  present  a  combination  of  the  peculiarities  of  scarla- 
tina and  measles,  but  the  whole  disease  is  usually  mild  and 
of  short  duration,  and  the  rash  disappears  in  three  or  foUr 
days.     Tlie  disease  is  communicated  by  a  special  infection 


TYPHUS    RASH.  Ill 

evidently  different  from  that  either  of  scarlatina  or  measles, 
and  a  previous  attack  of  one  or  both  of  these  diseases  does 
not  protect  the  patient  from  German  measles.  It  is  probable 
that  this  disease  is  often  involved  in  the  not  uncommon  re- 
ports of  children  having  had  measles  twice.  This  form  of 
eruption  is  sometimes  confused  with  a  copious  typhus  rash, 
as  well  as  with  scarlatina  and  measles.  It  also  resembles  the 
copaiba  rash. 

The  Typhus  rash  appears  from  the  fourth  to  the  seventh 
day,  usually  about  the  fifth  day  from  the  first  signs  of  acute, 
illness.  The  rash  is  but  rarely  absent  in  typhus  fever,  ex- 
cept in  mild  attacks  in  young  patients,  and  its  extent  and 
depth  bear  a  distinct  relation  to  the  severity  of  the  case.  It 
is,  however,  very  apt  to  be  overlooked  by  the  inexperienced 
owing  to  its  delicate  tint,  to  its  brief  duration  in  some  cases, 
or  to  the  absence  of  good  daylight  for  the  examination. 
Sometimes  the  inexperienced  look  too  closely  into  the  skin, 
and  so  fail  to  see  the  mottled  rash,  which  becomes  more  evi- 
dent when  looked  at  from  a  little  distance.  A  dirty  condition 
of  the  skin,  and  the  presence  of  flea  bites,  also  render  the 
recognition  of  a  typhus  rash  more  difficult.  Flea  bites,  in- 
deed, present  a  considerable  resemblance  to  typhus  spots  in 
certain  stages,  but  the  central  minute  dark  dot  or  bite  can 
often  be  recognized  ;  flea  bites  also  are  generally  aggregated 
on  covered  parts  of  the  body.  Before  the  rash  appears  in  a 
definite  form  there  is  often  a  congestion  or  redness  of  the 
skin,  well  shown  on  pressing  with  the  fingers,  especially 
over  the  back,  the  chest,  and  the  belly.  This  condition  is 
associated  with  suffusion  of  the  eyes,  and  a  dingy  complexion. 

There  are  two  elements  in  the  tj^phus  rash,  which,  how- 
ever, are  not  always  both  present — these  are  definite  spots 
and  a  more  general  mottling.  These  spots,  when  seen  im- 
mediately after  their  appearance,  are  usually  red,  perhaps 
slightly  elevated,  and  they  disappear  on  pressure.  They 
vary  in  size  up  to  about  a  quarter  of  an  inch  in  diameter, 
and  are  irregular  in  their  form.  In  a  day  or  two  they  be- 
come dirty  looking,  and  cease  to  disappear  on  pressure., 
Fresh  spots  may  appear  during  tlie  first  two  or  three  days  of 
the  eruption,  but  these  are  superadded  to  the  first  ones, 
which  remain.  The  spots  ultimately  become  bluish  or  red- 
dish-brown in  color,  and  distinct  petechite  or  subcutaneous 
hemori-hages  are  not  unfrequently  developed  in  the  typhus 
spots.  In  addition  to  the  distinct  spots  just  described,  we 
usually  have,  soon  after  they  appear,  a  general  mottling  of- 


112  CUTANEOUS    ERUTTIONS. 

tlie  skin,  as  if  tliere  Avere  a.  "  sub-cuticular"  eruption  of 
minute  spots.  This,  indeed,  may  be  the  only  eruption  visi- 
ble in  certain  cases,  especially  in  the  mild  forms.  This 
mottling  requires  a  good  light  for  its  observation,  and  the 
chest  and  abdomen  should  be  well  bared  for  the  examina- 
tion ;  pressure  of  the  fingers  is  useful  in  ascertaining  the 
presence  of  this  rash.  The  term  "  mulberry  rash"  has  been 
used  as  descriptive  of  the  general  appearance  of  the  typhus 
eruption.  The  parts  on  which  the  eruption  first  appears 
are  the  trunk,  more  especially  on  the  front,  the  parts  about 
the  front  of  the  shoulders,  and  sometimes  even  the  arms  and 
hands.  The  legs,  and  particularly  the  face,  are  less  affected, 
but  when  the  rash  is  copious  the  distribution  may  be  very 
general.  The  rash  persists  for  about  a  week  after  its  ap- 
pearance, fading  somewhat  as  improvement  begins,  or  be- 
coming blue,  dark,  or  petechial  as  death  approaches,  and  the 
spots  continue  to  be  visible  on  the  dead  body  if  the  rash  has 
existed  for  some  time. 

A  second  attack  of  genuine  typhus  is  very  rare,  but  owing 
to  the  frequent  confusion  of  enteric  fever,  and  perhaps  pneu- 
monia, with  this  disease,  the  mere  fact  of  a  former  attack 
being  alleged  cannot  be  much  relied  on  ;  but  special  inqui- 
ries as  to  the  place  in  which  the  illness  occurred,  and  as  to 
its  symptoms,  may  clear  up  the  doubts. 

The  eruptions  most  likely  to  be  confused  with  typhus  by 
the  inexperienced  are  those  of  measles,  German  measles,  and 
flea  bites.  A  rash  somewhat  resembling  that  of  typhus  ap- 
pears occasionally  in  relapsing  fever.  A  much  more  common 
error,  however,  consists  in  overlooking  the  presence  of  the 
rash  altogether. 

T7ie  JEnteric  Fever  eruption  is  almost  never  very  obtru- 
sive, and  so  it  is  seldom  noticed  by  the  public ;  as  a  rule  it 
requires  to  be  carefully  looked  for.  It  appears  chiefly  on 
the  trunk,  and  especially  on  the  abdomen,  but  an  examina- 
tion of  the  back  sometimes  discloses  the  only  spots  visible. 
The  eruption  consists  of  small  circular  rose-colored  papules 
(lenticular  spots)  not  exceeding  one-eighth  of  an  inch  in 
diameter ;  they  are  slightly  but  distinctly  elevated ;  they 
fade,  or  almost  disappear  on  gentle  pressure,  and  they  fade 
in  this  way  so  long  as  they  last,  differing  in  this  respect 
from  the  typhus  spots.  The  number  of  these  spots  in  a  case 
of  enteric  fever  varies  exceedingly ;  in  some  cases  only  two 
or  three  such  papules  can  be  found  on  a  careful  search  of  the 
whole  body,  and  in  others  there  may  be  twenty  or  thirty  on 


ENTERIC    FEVER    ERUPTION.  113 

the  abdomen.  The  abundance  of  the  eruption  bears  no're- 
lation  to  the  severity  of  the  case.  Some  cases  present  only 
one  or  two  spots,  although  carefully  examined  every  day, 
and  not  very  unfrequently  no  eruption  can  be  found  at  all. 
The  spots  appear  in  successive  crops,  each  crop  lasting  about 
four  or  five  days  before  disappearing.  Tliis  feature  of  a  suc- 
cession of  rose  spots  is  most  important  in  the  diagnosis.  It 
can  be  demonstrated  by  marking  with  ink  all  the  spots  visi- 
ble to-day,  say  with  a  circle,  those  which  appear  to-morrow 
with  a  triangle,  and  those  which  appear  next  witii  a  square  ; 
by  the  time  these  last  appear,  the  first  marks  will  be  found 
empty  or  containing  only  tlie  merest  trace  of  a  spot.  This 
eruption  seldom  appears  before  the  seventh  day  of  the  fever, 
but  its  appearance  is  often  much  later.  Fresh  eruptions  may 
continue  to  appear  until  convalescence  is  fairly  establislied, 
and  they  may  appear  during  a  relapse,  even  although  none 
were  present  in  the  first  attack. 

In  addition  to  those  rose-colored  lenticular  spots,  very 
delicate  blue  patches  (taches  bleuatres)  have  been  described 
in  this  fever  as  appearing  on  the  abdomen,  and  an  eruption 
of  sudamina  is  regarded  by  some  as  very  characteristic  of 
this  disease,  but  these  last  are  found  in  various  other  affec- 
tions.    (See  Sudamina,  infra.) 

The  chief  sources  of  fallacy  in  connection  with  the  erup- 
tion of  enteric  fever  are  : — (1)  An  imperfect  examination  of 
the  trunk  of  the  body.  (2)  Mistaking  the  presence  of  acci- 
dental pimples  for  true  "  rose  spots ;"  the  marking  and 
subsequent  observation  of  these  bring  out  their  difference. 
(3)  Typhus  spots  when  freshly  out  sometimes  resemble 
"  rose  spots,"  as  they  fade  on  pressure  at  this  time,  but  be- 
come persistent  after  a  day  or  two.  There  is  no  mottling 
between  the  enteric  rose  spots.  (4)  An  abundant  eruption 
of  "  rose  spots"  has  sometimes  been  confounded  with  a 
typhus  rash. 

(Enteric  fever  is  contagious  probably  chiefly  through  the 
intestinal  excretions ;  it  frequently  affects  various  inmates 
of  a  house  about  the  same  time,  and  arises  very  often  from 
bad  drains  or  leaking  soil  pipes  and  contaminated  water 
supply.  This  may  operate  in  poisoning  milk,  which  seems 
to  be  a  very  suitable  vehicle  for  the  propagation  of  the  poison. 
A  previous  attack  does  not  seem  to  afford  exemption  from  a 
second.) 

Sudamina  or  Milliary  Vesicles  are  minute  accumulations 
of  the  secretion  from  the  sweat  ducts,  arising  from  obstruc- 

10* 


114  CUTANEOUS    ERUPTIONS. 

tion  to  their  openings.  They  vary  in  size,  but  are  seldom 
larger  than  a  pin-head.  They  can  be  felt  as  giving  a  rough- 
ness to  the  surface,  and  can  be  seen  in  good  light  as  glitter- 
ing points.  Their  contents  are  usually  clear;  occasionally 
there  is  evidence  of  inflammatory  action  in  their  contents 
being  opaque  and  their  bases  inflamed.  (This  condition  has 
been  separated  from  sudamina  by  some,  and  named  "  mili- 
aria.") 

This  eruption  is  found  in  various  diseases,  characterized 
by  much  sweating,  and  has  no  specific  significance,  although 
formerly  regarded  in  this  light.  Sudamina  are  common  in 
enteric  fever,  acute  rheumatism,  phthisis,  and  after  child- 
birth. 

Erysipelas  is  characterized  by  redness  of  the  skin,  the 
inflammation  has  a  deeper  seat  than  in  erythema,  and  there 
is  usually  very  considerable  swelling  and  elevation  of  the 
aflected  part.  The  redness  is  usually  pretty  sharply  defined 
by  a  line  bounding  the  part  afi^ected,  and  it  extends,  as  a 
rule,  in  a  continuous  way  from  one  part  to  another.  Vesica- 
tion is  not  uncommon  in  erysipelas  if  severe,  and  even  the 
deeper  subcutaneous  tissue  may  be  involved  in  the  more 
serious  forms  (plilegmonous  erysipelas)  wliich  are  met  with 
in  surgical  practice.  Erysipelas  often  extends  from  wounds 
or  sores,  especially  when  it  arises  from  infection  ;  but  it  may 
be  idiopathic,  and  it  seems  at  times  to  arise  from  direct 
exposure  of  the  part  to  cold.  In  medical  practice  it  is  usu- 
ally found  attacking  the  head  and  face,  causing  much  swell- 
ing of  the  loose  tissues  about  the  eyes  and  nose.  Or  it  may 
attack  a  limb,  or  beginning  in  one  leg  it  may  spread  up  the 
thigh,  and  crossing  over  come  down  the  otlier  leg.  It  occurs 
in  newly  born  children,  spreading  sometimes  from  an  un- 
healthy umbilicus,  but  it  may  appear  in  older  children  also, 
apart  from  any  open  sore.  It  may  attack  puerperal  women, 
who  are  specially  liable  to  such  infection,  and  in  some  cases 
of  undoubted  erysipelas  no  rash  may  be  visible.  Sometimes 
in  grave  forms  of  erysipelas  the  patches  of  redness  are  irregu- 
lar and  fleeting,  readily  escaping  notice.  In  connection  with 
dropsy  of  the  legs,  whether  the  skin  gives  way  or  is  punc- 
tured, and  sometimes  apart  from  any  oozing  erysipelas  often 
forms  a  grave  complication. 


DISCOLORATION    OF    THE    SKIN.  115 

STAINING,  PIGMENTATION,  AND  DISCOLORATION 
OF  THE  SKIN. 

Suhcutaneous  hemorrhages  are  recognized  by  their  being 
unaffected  on  pressure.  When  small,  the  words  "petechife," 
or  "  ecchymoses"  are  used  ;  when  large,  the  term  "  vibices"  is 
sometimes  applied.  These  hemorrhages  are  found  in  typhus 
fever,  in  smallpox,  in  purpura,  in  scurvy,  in  diseases  of  the 
liver  and  spleen,  and  in  the  terminal  stage  of  dropsy  and 
other  exhausting  diseases.  AVe  must  examine  for  any  his- 
tory of  hemorrhage  from  the  nose,  gums,  or  bowels  in  cases 
of  purpura  (see  Hemorrhages,  Chapter  ix.) ;  and  we  may 
sometimes  find  sub-mucous  hemorrhage  in  the  mouth.  Pur- 
pura also  occurs  in  connection  with  rheumatic  affections  of 
the  joints.  In  suspected  scurvy  we  inquire  for  a  history  of 
deprivation  of  vegetables  and  milk  ;  this  may  readily  occur 
in  laborers,  who  often  live  on  tea,  and  bacon,  and  bread. 
The  presence  of  spongy  gums,  and  fetid  breath,  and  the 
existence  of  pain  and  hardness  near  the  hemorrhagic  patches, 
especially  in  the  calf,  usually  guide  us  aright.  In  disease  of 
the  liver,  leukajmia,  &c.,  the  spots  of  hemorrhage  seem  due 
to  a  depraved  state  of  the  blood.  In  typhus  fever,  small- 
pox, and  measles,  subcutaneous  hemorrhage  is  an  indication 
of  the  gravity  of  the  attack. 

Port-wine  stains,  ncEvi,  moles,  ^c,  need  only  be  men- 
tioned here.  Their  existence  since  childhood  and  their  gene- 
ral appearance  usually  prevent  any  misconception. 

Discoloration  of  the  shin  sometimes  results  from  external 
agencies,  as  the  application  of  iodine  or  nitrate  of  silver. 
Frequently  repeated  poulticing  and  blistering  may  likewise 
give  rise  to  a  dark  mottling  or  discoloration  of  the  skin.  On 
the  legs,  especially  of  old  people,  but  also  in  some  others,  we 
often  find  considerable  discoloration  and  mottling  from  the 
patients  sitting  much  with  their  legs  near  the  fire. 

Of  medicines  administered  internally,  nitrate  of  silver  may 
be  mentioned  as  giving  rise  to  a  dark  bluish  discoloration  of 
those  parts  of  the  skin  exposed  to  the  light.  This  is  a  rare 
accident  nowadays,  but  with  such  a  discoloration,  especially 
in  one  subject  to  epileptic  fits,  we  must  inquire  whether  this 
remedy  had  been  used. 

The  discoloration  of  jaundice  is  described  elsewhere,  and 
some  of  the  conditions  most  likely  to  be  confounded  with  it 
are  there  referred  to.   (See  Chapter  xii.)    Chlorosis,  syphilis, 


116 


CUTANEOUS    ERUPTIONS. 


malarial  fevers,  and  cancers  all  produce  an  unliealthy-looking 
discoloration  of  the  skin. 

Great  exposure  to  the  air  and  weather,  associated  with 
nncleanliness,  gives  rise  to  a  darkening  of  the  skin  with 
brownish  spots  and  freckles,  and  sometimes  to  a  more  gene- 
ral and  uniform  discoloration  (vagabondismus).  Sailors 
and  others  exposed  to  tropical  climates  have  frequently  a 
swarthy  look,  and  the  influence  of  race  must  not  be  for- 
gotten. 

In  phthisis,  also,  we  sometimes  see  considerable  pigmenta- 
tion about  the  cheek-bones  and  around  the  orbits.  In  pityri- 
asis versicolor,  there  are  defined  patches  of  brownish  dis- 
coloration, with  minute  scales,  situated  usually  on  the  chest, 
or  at  least  on  the  trunk ;  the  parasitic  nature  of  this  erup- 
tion can  be  demonstrated  by  the  microscope  (see  Fig.  22). 


Fig.  22. — Microsporon  Furfur,  the  vegetable  parasite  of  Pityriasis  versicolor. 
(Dr.  MTall  Anderson.) 


Pregnancy  is  often  characterized  by  considerable  pigmen- 
tation. It  is  chiefly  marked  around  the  nij^ple,  about  the 
linea  alba,  and  on  the  face.  In  uterine  tumors,  and  in  other 
forms  of  uterine  disease,  there  are  often  distinct  patches  of 
brownish  discoloration  on  the  face,  chiefly  on  the  brow,  but 
other  parts  may  also  be  affected  (chloasma  uterinum). 

In  Addison's  disease,  the  pigmentation  affects  chiefly  the 
face,  the  exposed  part  of  the  neck,  the  backs  of  the  hands, 
the  axillary  and  umbilical  regions,  the  genitals  and  the  in- 
ner aspect  of  the  thighs.  This  discoloration,  as  a  rule, 
resembles  the  tint  of  a  mulatto's  face,  but  in  some  parts  the 


SYPHILITIC    ERUPTIONS.  lit 

discoloration  is  darker.  In  many  cases  considerable  ass"ist- 
ance  is  experienced  by  finding  brownish  stains  or  black 
streaks  on  the  buccal  mucous  membrane  and  on  the  tongue 
and  the  nipples.  The  constitutional  symptoms  associated 
with  the  pigmentation  in  Addison's  disease  are  those  of  as- 
thenia rather  than  of  emaciation,  with  great  feebleness  of  the 
muscles,  including  the  heart  itself.  Pains  in  the  back  and 
vomiting  are  not  uncommon.  The  disease  is  often  compli- 
cated with  pulmonary  phthisis,  or  disease  of  the  vertebra, 
but  the  diagnosis  can  be  most  safely  arrived  at  when  the 
prostration  and  discoloration  seem  otherwise  inexplicable. 
It  is  commonest  in  young  male  adults ;  greater  care  is  re- 
quired in  the  diagnosis  in  the  case  of  women,  and  especially 
if  there  be  any  uterine  irregularity.  The  presence  of  hepatic 
or  renal  disease  ought  also  to  make  us  more  "uarded  in  our 
diagnosis. 

White  patches  of  skin  may  result  from  cicatrices  of  all 
kinds.  White  streaks  are  seen  in  connection  w^ith  atropine 
lesions  of  the  skin,  which  may  be  associated  with  evidence 
of  defective  formation  elsewhere.  White  vertical  lines  on 
the  abdominal  walls  are  found  habitually  in  women  who 
have  borne  children :  they  sometimes  guide  us  in  forming  an 
opinion  as  to  this  fact.  They  arise  from  previous  distension, 
for  similar  streaks  are  found  in  persons  of  both  sexes  and  in 
children,  in  connection  with  former  dropsical  swellings  of 
the  belly.  White  patches  from  simple  absence  of  pigment 
in  the  skin  are  named  vitiligo  or  leucoderma.  Absence  of 
pigment  in  the  skin,  hair,  and  choroid  constitutes  albinism. 

SYPHILITIC  ERUPTIONS. 

Syphilitic  eruptions  assume  nearly  every  variety  of  appear- 
ance found  in  disease  of  the  skin.  It  is  of  more  importance 
to  recognize  an  eruption  as  syphilitic,  than  to  define  its  spe- 
cial form. 

The  following  points  for  such  a  discrimination  ai'e  given 
by  Dr.  Tilbury  Fox:  1.  Previous  syphilitic  infection,  as 
evidenced  by  the  history,  by  cicatrices  of  the  primary  sores, 
&c.  2.  The  symmetry  of  syphilitic  eruptions.  3.  Their 
so-called  "copper  color:"  dull  red  at  first,  becoming  reddish 
yellow-brown.  4.  A  tendency  to  circular  form  of  the  patches. 
5.  The  scales  when  present  are  very  light  and  small.  6. 
The  crusts  are  thick,  greenish,  or  black,  and  adhere  firmly; 
vesicles  are  flat,  and  do  not  rupture  readily;  ulceration  is 


118^  CUTANEOUS    ERUPTIONS. 

common,  the  surface  ashy  gray,  and  the  edges  sharp.  7. 
Pain  and  itching  in  the  parts  are  not  usually  troublesome. 
8.  Polymorphism :  papules,  pustules,  and  tubercles  coexist 
in  the  same  subject,  or  one  form  of  eruption  gradually  assumes 
the  character  of  another. 

As  to  the  diflferent  periods  of  syphilitic  eruptions  he  gives 
the  following  chart : — 

1st  period Syphilitic  fever,  with  transient  hyperemia  of 

the  skin,  giving  rise  to  roseola,  &c.  (about  the  same 
time  as  the  sore  throat — a  few  weeks  after  infection). 
2d  period Hyperaemia  and  infiltration  about  the  seba- 
ceous glands — syphilitic  acne. 

Hyperaimia  and  deposit  in  the  hair  follicles,  syphilitic 
lichen. 

Ditto.     In  the  derma — papular,  and  tubercular,  squa- 
mous and  pustular  syphilis. 

About  the  nerves,  syphilitic  herpes  and  pemphigus. 

3d    period Characterized   by   changes    in    pre-existing 

syphilitic  formations  which  lead  to  syphilitic  ulceration, 
exostosis,  &c. 
In  congenital  syphilis  we  look  for  mucous  tubercles  at  the 
anus  or  mouth,  red  patches  or  pustules  on  the  buttocks, 
ankles,  or  hands,  subacute  onychia,  fissure  at  the  lips ;  a  his- 
tory of  "snuffles"  at  birth,  and  the  presence  of  notched  teeth 
or  of  old  keratitis  are  important. 

AFFECTIONS  OF  THE  NAILS. 

Affections  of  the  nails  sometimes  serve  to  indicate  consti-' 
tutional  disorders :  there  are,  also,  of  course,  local  affections 
of  the  parts. 

Curving  of  the  nails  is  observed  along  with  a  clubbed 
shape  of  the  finger  ends,  in  cases  of  phthisis  ;  sometimes  the 
curving  exists  without  any  of  the  clubbing  referred  to.  This 
deformity  is  not  limited  to  phthisis,  but  is  found  in  various 
chronic  states  tending  to  atrophy.  It  may  be  found  in  cardiac 
and  aneurismal  disease,  and  in  the  latter  is  sometimes  on  one 
side  only. 

Transverse  ivkite  marks,  or  thinned  portions  in  the  nails, 
are  sometimes  clearly  seen  after  serious  illnesses,  such  as 
fevers,  and  we  may  occasionally  avail  ourselves  of  them  in 
checking  the  history  or  the  dates  supplied  by  a  patient.  A 
mark  of  this  kind  half  way  up  the  nail  may  be  reckoned  as 
indicating  an  illness  three  or  four  months  previously. 


GLANDULAR    AFFECTIONS.  119 

The  nails  are  sometimes  shed  in  pityriasis  rubra,  and  in 
severe  eczema  affecting  their  neighborhood.  In  psoriasis 
and  pityriasis  rubra,  the  nails  are  often  affected,  becoming 
dingy,  tliickened,  curved,  grooved,  and  dirty  looking. 

Onychia,  inflammation  of  the  matrix  of  the  nail  with  sup- 
puration beneath  it,  and  loosening  of  its  attachments,  is 
occasionally  due  to  syphilitic  disease.  Parasitic  diseases 
sometimes  affect  the  nails  (favus  and  ringworm). 

GLANDULAR  AFFECTIONS. 

Affections  of  the  lymphatic  glands  afford  many  indications 
of  general  constitutional  states.  They  are  often,  however, 
merely  dependent  on  local  irritation.  Thus  a  sore  on  the 
foot  or  leg,  perhaps  of  a  trivial  nature,  may  by  the  strain  of 
walking  give  rise  to  enlargement  and  tenderness  in  the 
femoral  glands ;  the  anatomical  relationship  of  the  lymph- 
atics serves  to  indicate  the  connection  of  these  with  the  leg, 
instead  of  the  genital  organs  as  might  at  first  be  supposed. 
In  the  neck,  also,  the  posterior  cervical  glands  may  be  en- 
larged from  the  irritation  of  an  eczema  of  the  scalp,  past  or 
present,  and  not  as  the  result  of  constitutional  syphilis.  A 
chain  of  small  hard  glands  in  this  situation,  however,  consti- 
tutes an  important  indication  of  constitutional  syphilis,  in 
the  absence  of  any  local  cause  for  their  enlargement.  The 
inguinal  glands  are  often  enlarged,  and  sometimes  proceed 
to  suppui'atiou,  from  the  irritation  of  a  gonorrhoea  or  of  a 
soft  chancre  on  the  penis  :  indeed,  the  history  of  suppurating 
buboes  and  the  presence  of  cicatrices  in  the  groin  are  to  be 
regarded  as  evidence  of  some  local  irritation  in  the  genital 
organs,  rather  than  a  proof  of  constitutional  syphilis  ;  this 
may,  however,  coexist  with  the  other.  The  typical  form  of 
glandular  enlargement  in  the  groin  due  to  syphilis,  consists 
rather  in  the  presence  of  a  group  of  moderately  enlarged, 
painless,  and  movable  or  rolling  glands,  which  proceed  to 
suppuration  only  in  exceptional  cases. 

Enlargement  of  the  glands  elsewhere  may  be  due  to  syphi- 
lis in  the  exceptional  case  of  a  primary  sore  being  contracted 
in  some  unusual  situation :  a  general  affection  of  the  whole 
glandular  system  is  also  found  at  times  in  constitutional 
syphilis. 

Enlargement  of  the  glands  serves  as  a  valuable  indication 
of  an  affection  of  the  system  in  certain  forms  of  cancer  and 
epithelioma ;  malignant  tumors  of  the  breast  affect  the  axil- 


120  GLANDS. 

lary  glands,  malignant  growths  in  the  throat  affect  the  cervi- 
cal glands,  and  so  on.  Even  deep-seated  cancers  may  reveal 
themselves  by  snch  glandular  affections,  as  in  tlie  case  of 
malignant  growths  at  the  base  of  the  skull  involving  the 
glands  in  tlie  neck,  and  cancer  of  the  abdominal  organs 
affecting  some  part  of  the  lymphatic  system  within  our  reach. 

Enlargement  of  the  anterior  cervical  glands  is  due  in  the 
immense  majority  of  cases  to  a  scrofulous  tendency  in  the 
patient,  and  their  presence,  or  the  evidences  of  their  former 
existence,  from  the  scars  and  cicatrices  left,  frequently  serve 
to  indicate  this  constitutional  taint.  They  may,  however, 
be  due  to  some  of  the  other  causes  referred  to  in  this  section. 
The  scrofulous  glands  sometimes  remain  chronically  enlarged, 
although  free  from  pain.  In  persons  of  a  weak  constitution, 
the  lymphatic  glands  are  sometimes  enlarged  from  exposure 
to  cold  and  other  comparatively  slight  causes  which  would 
not  affect  a  robust  person.  Scrofulous  glands  may  occasion- 
ally be  felt  through  the  abdominal  walls  in  cases  of  tabes 
mesenterica. 

A  generalized  enlargement  of  the  lymphatic  glands  is  so 
often  associated  with  Leukaemia^  that  it  is  well  to  examine 
the  blood  microscopically  Avhen  they  are  thus  affected.  The 
relative  proportion  of  white  blood  corpuscles  to  the  red  cor- 
puscles varies  greatly  even  in  health,  and  it  is  often  consider- 
ably increased  in  anaemia  and  also  in  cancerous  affections, 
but  when  the  proportion,  as  estimated  carefully  in  various 
fields  of  the  microscope,  amounts  to  1  in  20  or  1  in  10,  the 
case  may  be  regarded  as  one  of  leukaemia ;  the  proportion  is 
often  higher,  and  the  white  corpuscles  may  even  equal  the 
red  in  number.  (See  Examination  of  the  Blood,  Chapter 
ix.)  In  such  cases  we  must  see  if  there  is  any  enlargement 
of  the  spleen.  Leukaemia  may  exist  with  enlargement  of 
the  lymphatics  alone  (lymphatic  leukaemia),  or  with  en- 
largement of  the  spleen  alone  (splenic  leukaemia),  or  both 
forms  of  enlargement  may  be  present.  General  enlai'gement 
of  the  lymphatic  glands  may  exist  without  leukaemia,  al- 
though dependent  on  some  grave  constitutional  affection ; 
the  name  "  Hodgkin's  Disease"  is  sometimes  applied  to  this 
special  variety,  although  it  is  applied  by  others  in  a  more 
general  sense  to  cases  of  various  kinds  with  lymphatic  en- 
largements (lymphadenoma).  In  such  cases  there  is  some- 
times a  complication  from  the  presence  of  a  mediastinal  or 
abdominal  tumor  (lymphoma)  of  a  similar  nature  ;  these  may 


LYMPHADENOMA,  121 

give  rise  to  exudations,  and  so  tlie  case  may  be  mistakeiT  for 
a  pleurisy  or  for  ascites  occurring  in  a  scrofulous  subject. 

Enlargement  of  the  cervical  glands  is  of  habitual  occur- 
rence in  scarlet  fever ;  it  sometimes  appears  very  early  in  the 
disease,  before  the  other  symptoms  have  been  developed,  but 
usually  comes  on  about  the  second  or  third  day  of  the  illness, 
or  even  later.  It  is  specially  marked  in  the  grave  forms 
with  serious  affection  of  the  throat ;  in  young  children,  the 
enlarged  glands  may  appear  like  a  collar  surrounding  the 
neck,  this  is  always  a  very  serious  indication.  Glandular 
affections  in  connection  with  ulceration  of  the  throat,  ap- 
pearing late  in  the  course  of  the  fever,  are  always  of  special 
gravity.  In  scarlatina,  these  glands  often  suppurate,  and 
sometimes  cause  extremely  deep  sloughs. 

Glandular  enlargements  in  the  neck,  especially  about  the 
angle  of  the  jaw,  are  sometimes  found  in  diphtheria  and 
other  forms  of  sore  throat  and  tonsillitis,  but  they  seldom 
attain  the  size  or  extent  common  in  scarlet  fever. 

Parotitis. — Inflammation  and  suppuration  of  the  parotid 
may  be  due  to  scarlet  fever,  from  the  general  invasion  of  the 
glands  in  this  region.  It  constitutes  a  sequela  of  typhus 
which  is  not  uncommon.  It  is  but  rarely  seen  in  relapsing 
and  other  fevers  or  in  erysipelas.  Parotitis,  however,  may 
also  be  a  special  affection,  due  to  some  specific  infection 
(mumps).  This  disease  attacks  children  chiefly,  especially 
between  five  and  fifteen  years.  Sometimes  it  is  uuilateral 
but  usually  double.  There  is  considerable  pain,  especially 
on  moving  the  jaws,  and  a  certain  amount  of  fever  and  con- 
stitutional disturbance  is  common.  This  form  of  parotitis 
seldom  proceeds  to  suppuration.  Occasionally  affections  of 
the  breast  or  testicle,  by  metastasis,  have  been  observed. 

Plague,  Glanders,  8^c Acute  glandular  swelling  (buboes) 

in  the  axilla,  groin,  and  neck  are  found  as  a  rule  in  the 
Plague,  associated  often  with  carbuncles  and  other  evidence 
of  serious  disturbance,  but  this  disease  is  not  now  prevalent 
in  Europe. 

Glandular  swellings  are  likewise  found  in  connection  with 
glanders  and  farcy,  as  it  occurs  in  men  infected  from  hoi'ses, 
asses,  and  mules ;  sometimes  pustular  eruptions  and  dis- 
charges from  the  nose  appear  in  this  disease. 

11 


122  JOINTS. 


THE  JOINTS. 


The  joints  should  be  examined  in  all  cases  in  wliich  they 
seem  painful.  AYhen,  from  the  presence  of  fever  or  any  other 
cause,  we  suspect  the  existence  of  acute  rheumatism,  gout,  or 
pya?mia,  we  mvist  make  a  careful  search  in  the  joints  for  any 
swelling  or  tenderness.  In  syphilis,  also,  the  history  of- 
pain  in  the  joints  is  often  important.  The  presence  of 
chronic  disease  of  the  joints,  or  the  evidence  of  past  mischief 
in  them,  may  often  throw  light  on  the  scrofulous  or  gouty 
tendencies  of  a  patient;  the  evidence  of  old  disease  in  the 
joints,  or  former  suppuration,  may  serve  to  explain  the  ex- 
istence of  lardaceous  disease  of  the  viscera.  Local  disease 
of  the  joints  comes  for  the  most  part  under  the  care  of  the 
surgeon  ;  the  discrimination  of  the  various  lesions  from  one 
another,  and  from  hysterical  affections,  which  occasionally 
assume  this  form,  must  be  sought  in  surgical  works. 

On  the  border  line  between  medicine  and  surgery  is  the 
form  of  disease  popularly  called  '■^rheumatic  gout,'''  but  more 
correctly  named  '■'•rheumatoid  arthritis"  or  '■'■chronic  rheu- 
matic, arthritis ;"  this  is  characterized  by  more  or  less  pain, 
but  especially  by  enlargement  of  the  ends  of  the  bones,  and 
deformity  or  "nodosity  of  the  joints;"  the  parts  involved  are 
often  twisted  out  of  their  position.  The  knuckles  are  per- 
haps the  parts  most  frequently  involved  in  the  early  stage, 
but  all  the  joints  of  the  limbs  may  be  more  or  less  affected. 
A  certain  crackling  sensation  is  often  experienced  in  moving 
or  manipulating  such  joints.  Although  essentially  a  chronic 
disease,  the  patient  may  have  acute  or  subacute  attacks ;  we 
then  find  redness,  swelling  Avitli  efliision,  and  tenderness:  in 
some  cases  there  may  be  a  considerable  resemblance  to  gout. 
Enlargement  of  the  ends  of  the  bones  always  implies  an  old 
standing  affection ;  osseous  deposits  may  likewise  exist  in 
the  adjoining  ligamentous  tissues.  The  general  health  is 
usually  deteriorated,  and  the  articular  mischief  often  dates 
I'rom  some  debilitating  or  exhausting  illness. 

Enlargement  of  the  ends  of  the  bones,  and  other  osseous 
growths  and  deformities  resulting  from  spontaneous  fractures, 
are  met  with  occasionally  in  cases  of  locomotor  ataxy. 
Chalky  deposits  in  the  joints  sometimes  stimulate  the  de- 
formity of  rheumatoid  arthritis,  and  some  doubt  may  remain 
in  certain  cases  till  the  deposits  are  exposed  by  ulceration. 
Enlargement  of  the  ends  of  the  bones,  with  the  appearance 


RHEUMATISM.  123 

of  "double  joints,"  occurs  in  children  as  one  of  the  charac- 
teristics of  rickets. 

In  acute  rheumatism  (rheumatic  fever)  pain  in  the  joints 
is  usually  an  early  symptom,  although  there  may  be  high 
fever  for  a  day  or  two  before  this  becomes  pronounced. 
When  the  pains  are  present  in  various  joints  we  can  seldom 
mistake  the  nature  of  the  illness.  But  when  the  joints  of 
the  spine  seem  the  only  parts  affected,  we  may  indeed  be  in 
doubt,  as  pain  of  this  kind  often  arises  from  serious  disease 
of  the  bones,  or  from  certain  affections  of  the  spinal  cord,  or 
of  its  membranes.  For  this  reason  any  case  of  rheumatism, 
with  acute  symptoms,  involving  the  back  chiefly,  without 
any  swelling  of  the  joints  in  the  limbs,  must  always  be  scruti- 
nized carefully  during  its  progress,  as  many  mistakes  arise 
from  applying  the  name  "  rheumatism"  to  such  an  illness ; 
pain  in  the  limbs,  with  great  tenderness  on  handling  tliem, 
may  be  present  in  the  spinal  affections  referred  to,  and  this 
tends  further  to  simulate  rheumatism ;  more  rarely,  cerebral 
meningitis  may  be  characterized  by  hypera^sthesia  in  this 
way.  When  the  patient  is  known  to  have  had  articular 
rheumatism,  the  case  is  so  far  simplified ;  a  rheumatic  attack 
may  be  confined  chiefly  to  the  back,  but  it  usually  involves 
other  joints  also  during  some  part  of  its  course. 

Acute  rheumatism  usually  produces  very  marked  swelling, 
with  considerable  effusion  into  the  joints,  and  along  with 
this  there  is  often  redness  of  the  skin,  and  almost  always 
great  pain,  especially  on  disturbing  their  |X)sition  in  any 
way,  so  that  the  patient  becomes  very  helpless,  and  dreads 
the  least  shaking  of  his  bed.  The  mischief  in  the  joints 
appears  very  suddenly;  it  is  sometimes  very  fleeting,  shifting 
about  from  one  limb  or  one  set  of  joints  to  another,  or  from 
one  side  of  the  body  to  the  other.  Relapses  are  very  com- 
mon in  this  disease,  and  one  attack  predisposes  to  another. 
We  inquire  in  cases  of  this  kind  for  the  history  of  any  pre- 
vious attacks,  of  any  exposure  to  cold  and  wet,  and  also  for 
any  hereditary  tendency  to  rheumatism.  We  must  always 
make  a  careful  search  for  the  evidence  of  cardiac  mischief; 
this  may  exist  apart  from  any  thoracic  symptoms  ;  there  is, 
however,  usually  more  or  less  pain  in  the  chest  when  peri- 
carditis is  present.  The  temperature  of  the  patient  is 
very  important  in  rheumatism ;  a  strict  w^atch  must  be  kept 
on  it  if  it  seems  to  be  rising  very  high.  With  such  an  ele- 
vation we  may  have  alarming  delirium  or  other  cerebral 
symptoms,  although  the  articular  pains  may  be  but  slight  or 


124  JOINTS. 

may  even  have  greatly  diminished.  Sweating  is  habitual  in 
actite  rheumatism,  and  the  urine  is  usually  high-colored  and 
loaded  with  urates. 

In  children,  the  aiFection  of  the  joints  in  rheumatism  is 
often  so  slight  and  fleeting,  that  the  disease  is  apt  to  be  over- 
looked, or  attributed  to  "  growing  pains."  In  such  cases 
swelling  and  pain  about  the  leet  are  often  the  most  marked 
features.  These  slight  attacks  may  be  complicated  with  en- 
docarditis or  pericarditis,  and  may  lay  the  foundation  of  per- 
manent cardiac  disease. 

Chronic  forms  of  rheumatism  are  found  in  elderly  people, 
apart,  it  may  be,  from  any  previous  acute  attacks.  This 
affection  is  characterized  by  pain  and  stiffness  of  the  joints, 
and  the  muscles  and  tendinous  structures  ai"e  also  more  or 
less  involved. 

Quasi -rheumatic  affections  of  the  joints  occur  in  scarla- 
tina and  relapsing  fever.  In  the  former  the  articular  affec- 
tion occurs  usually  after  the  first  violence  of  the  fever  is  over, 
and  often  coincides  with  the  period  of  albuminuria  and  cuta- 
neous desquamation.  There  is  not  usually  much  swelling  in 
the  joints,  but  the  pain  is  sometimes  very  considerable.  (For 
more  serious  articular  affections  in  scarlatina,  see  Pytemic 
affections  of  joints,  p.  126.) 

In  relapsing  fever,  pains  in  the  joints  occur  at  the  begin- 
ning of  tlie  febrile  attack,  and  often  add  materially  to  the 
general  suffering.  They  may  also  return  with  the  relapse. 
The  presence  of  high  fever  and  of  articular  pains  in  this 
disease  simulates  acute  rheumatism  very  closely,  but  the  epi- 
demic character  of  relapsing  fever,  and  its  complete  absence 
for  years  together  in  this  country,  prevent  any  very  I'requent 
errors  in  this  respect.  Here  also  the  joints  are  but  little 
swollen  as  compared  with  tlie  usual  foim  of  rheumatism. 
Arthritic  pains  and  swelling  occur  in  connection  with  purpura 
(see  pp.  115  and  127),  and  also  with  the  Haemorihagic  dia- 
thesis (see  Chapter  ix.) 

Gororrhoecil  rheumatism  (gonorrhoeal  synovitis)  is  com- 
paratively a  rare  affection.  It  must  not  be  supposed  to  in- 
clude all  the  cases  of  chronic  articular  pains  in  patients  who 
have  had  at  some  time  a  gonorrhoeal  discharge.  Gonorrhceal 
rheumatism  arises  during  the  ])eriod  of  the  urethral  discharge. 
It  usually  attacks  the  knee  joint,  but  it  may  involve  various 
joints  in  succession,  and  even  the  synovial  sheaths  of  the 
tendons.  Its  appearance  may  be  marked  by  a  diminution  in 
the  discharge.     It  tends  to  recur  with  a  subsequent  gonor- 


GOUT,  125 

rhoeal  infection,  or  even  with  other  forms  of  urethral  irrita- 
tion, or  it  may  linger  as  a  more  chronic  affection  associated 
with  a  gleety  discharge,  or  even  after  this  has  disappeared  ; 
recurring  disease  is  apt  to  lead  to  serious  destruction  or  to 
stiffness  of  the  joint ;  although  the  health  suffers  seriously, 
the  patients  do  not  often  die  of  the  disease.  Occasionally 
this  gonorrhoeal  rheumatism  is  associated  with  ophthalmia  at 
its  commencement,  and  with  iritis  in  its  later  stages.  As  a 
rare  occurrence  we  may  have  true  pyemic  synovitis  from 
gonorrhoea,  with  its  usual  fatal  result. 

Gout  manifests  itself  by  pain  and  swelling  in  the  joints, 
associated  with  more  or  less  general  disturbance  ;  and  it  ap- 
pears both  in  acute  and  chronic  forms.  Gout  has  a  special 
tendency  to  affect  the  ball  of  the  great  toe,  especially  in  the 
first  attack,  but  almost  any  joint  may  be  involved  ;  previous 
injury  renders  a  joint  particularly  liable  to  the  gouty  inflam- 
mation, and  this  may  determine  the  site  of  the  seizure.  The 
joint  becomes  exceedingly  painful  in  an  acute  attack,  espe- 
cially if  it  be  the  first ;  there  is  usually  great  swelling,  redness 
or  lividity,  and  tension;  the  veins  are  usually  much  swollen, 
and  after  the  tension  subsides  ojdema  of  the  part  remains, 
and  the  skin  desquamates.  The  paroxysms  of  pain  have  a 
marked  tendency  to  nocturnal  exacerbations.  The  fever  is 
usually  much  less  than  in  rheumatism,  and  its  intensity  seems 
more  distinctly  related  to  the  local  inflammation.  General 
disturbance  and  especially  gastric  disorder,  characterized  by 
acidity,  may  be  regarded  as  usual,  and  cramps  in  the  muscles 
are  not  uncommon.  Alarming  symptoms  referable  to  the 
stomach,  heart,  or  nervous  system  sometimes  occur  in  connec- 
tion with  gouty  attacks,  or  with  a  recession  of  the  articular 
affection.  The  fleeting  and  erratic  forms  of  attack  common 
in  I'heumatism  are  not  found  in  gout. 

The  personal  and  family  history  are  very  important  in  the 
diagnosis  of  gout  in  doubtful  cases.  Gout  is  rare  in  Scot- 
land except  among  the  upper  chisses,  although  not  uncom- 
mon amongst  working  men  and  hospital  patients  in  London. 
Is  is  commoner  in  men  than  women,  and  seldom  appears  till 
the  patient  is  near  40  years  of  age.  The  influence  of  here- 
dity is  very  strongly  marked.  The  habits  of  the  patient  as 
to  excess  in  eating  and  drinking  are  very  important ;  the  use 
of  malt  liquors  and  wines  predisposes  to  gout  much  more 
strongly  than  even  a  free  use  of  spirits.  Excess  in  the  use 
of  animal  food  is  likewise  potent  in  producing  gout.  The 
connection  of  lead-poisoning  with  gout  seems  also  to  be  so 

11* 


126  JOINTS. 

freqvieiit,  in  London  at  least,  as  to  assist  in  the  diagnosis. 
The  occurrence  of  renal  affections  in  gout  is  likewise  com- 
mon, and  should  be  inquired  into,  and  the  state  of  the  heart 
and  arteries  should  likewise  be  investigated. 

The  test  of  the  gouty  condition  by  linding  crystals  of  uric 
acid  in  the  serum  of  the  blood  is  of  much  value.  Dr.  Gar- 
rod  recommends  two  drachms  of  the  serum  of  the  blood  to 
be  placed  in  a  flat  glass  dish  and  set  aside  to  evaporate 
slowly  ;  it  is  first  acidulated  slightly  with  acetic  acid,  and  a 
fine  linen  fibre  is  introduced  into  it ;  when  the  fluid  has  been 
reduced  to  the  consistency  of  a  jelly,  this  fibre  is  found 
crusted  over  with  crystals  of  uric  acid  if  the  blood  be  de- 
rived from  gouty  patients,  but  there  are  no  crystals  from  the 
blood  of  those  free  from  this  taint. 

Chronic  forms  of  gout  become  developed  from  repetitions 
of  the  acute  affection.  In  gout  the  tendency  is  for  the  recur- 
rences to  be  more  and  more  frequent,  with  less  distinct 
causes  for  each  attack.  The  joints  also  are  apt  to  become 
permanently  changed,  particularly  from  the  deposit  of  chalky 
masses  in  their  structures.  These  are  called  chalk  stones  or 
tophi  {i.  e.,  concretions)  ;  they  consist  chiefly  of  urate  of 
soda  along  with  animal  matter ;  their  composition  may  be 
determined  as  in  the  case  of  urinary  calculi.  Sometimes 
these  concretions  give  rise  to  small  abscesses,  and  in  this 
way  become  exposed.  They  are  found  in  various  joints. 
Before  they  become  visible  the  diagnosis  of  these  hard  masses 
in  the  joints  may  be  doubtful,  as  they  may  simulate  some 
enlargement  of  the  ends  of  the  bones.  Assistance  is  afforded 
at  times  by  finding  similar  small  concretions  in  the  ear,  espe- 
cially in  the  helix,  varying  in  appearance  from  the  minutest 
possible  vesicle  beneath  the  skin  to  a  bead-like  nodule 
resembling  a  pearl. 

The  constitutional  symptoms  in  chronic  gout  vary  consid- 
erably; dyspeptic  troubles  form  the  leading  feature  in  such 
cases. 

PycBinic  affections  of  the  joints  occur  in  many  cases  of 
pyaemia,  as  they  arise  in  surgical  practice.  With  these  we 
have  no  concern  here.  Affections  of  this  kind  occur  after 
childbirth,  sometimes  at  a  considerable  time  after  delivery, 
associated  it  may  be  with  evidence  of  suppuration  elsewhere 
{pelvic  abscess,  phlebitis,  'pycemia,  8^c.).  Essentially  the 
same  kind  of  articular  mischief  occurs  also  sometimes  in 
scarhitina.  This  puerperal  and  scarlatinal  form  of  pyjemic 
arthritis  is  limited  to  one  joint  in  some  cases,  but  in  others 


PYEMIA — PURPUKA — SYPHILIS.  127 

various  joints  are  affected.  Such  illness,  although  always 
serious,  are  not  necessarily  fatal.  Pyaemic  disease  of  the 
joints  sometimes  occurs  also  after  certain  forms  of  pneu- 
monia, "vvith  typhoid  symptoms,  and  after  enteric  and  some 
other  fevers.  When  suppuration  is  known  to  be  going  on 
in  a  case,  we  must  always  regard  articular  pains  with  great 
suspicion  ;  gonoi'rhoea  has  been  known  to  give  rise  to  true 
pygemia,  and  gonorrha?al  rheumatism  is  regarded  by  some  as 
a  mild  form  of  this  disease. 

Pyaemia,  with  affection  of  the  joints,  sometimes  occurs  in 
an  idiopathic  form,  as  it  may  be  called,  that  is,  without  any 
obvious  cause.  In  such  cases  the  symptoms  may  resemble 
those  of  enteric  fever,  although  shiverings  are  usually  present 
in  a  more  pronounced  ibrm.  In  obscure  cases  it  is  well  to 
examine  the  various  joints  as  to  swelling,  redness  and  tender- 
ness to  pressure. 

Pyaemic  joints  are  usually  painful,  but  sometimes  the  pain 
is  not  well  marked ;  tenderness  is  veiy  generally  present 
even  in  such  cases.  The  pyaemic  affection  has  none  of  tiie 
fleeting  or  shifting  character  of  acute  rheumatism.  Actual 
pointing  of  a  pyasmic  joint  may  take  place. 

Articular  pains  with  subcutaneous  hemorrhages  occur 
both  in  pur])ura  and  scurvy.  There  is  a  form  of  disease 
termed  "  purpura  rheumatica,"  in  which  further  pains  and 
fresh  hemorrhagic  spots  appear  together,  and  there  may  be 
hemorrhages  elsewhere  as  well  ;  it  is  regarded  by  some  as  a 
mere  coincidence  of  purpura  with  a  rheumatic  attack.  Jn 
scurvy  the  articular  pains  and  stiffness  of  joints,  due  to  the 
fibrinous  effusions  found  in  this  disease,  are  often  so  perma- 
nent as  to  lead  to  the  idea  of  rheumatic  instead  of  scorbutic 
disease.  Affections  of  the  joints  are  also  found  in  the  hemor- 
rhagic diathesis.     (See  Hemorrhages,  Chapter  ix.) 

Syphilitic  affections  of  the  hones  and  joints  occur  in  a 
slight  form  in  what  is  termed  the  secondary  stage.  But  the 
more  severe  and  persistent  pains  occur  later,  among  the  terti- 
ary symptoms,  when  nodes,  &c.,  become  developed.  These 
pains  usually  affect  several  joints,  and  especially  involve  the 
larger  ones  ;  they  have  a  very  marked  tendency  to  nocturnal 
exacerbations,  and  the  pains  are  often  evidently  present  in 
the  bones,  and  even  in  the  head,  as  well  as  the  joints. 
Other  evidences  of  syphilis  usually  coexist  with  these  pains 
when  they  are  severe.  This  manifestation  of  syphilis  has 
some  value  in  judging  of  the  history  of  a  venereal  complaint. 


128 


CHAPTER  V. 

EXAMINATION  OF  THE  ORGANS  OF  SPECIAL 
SENSE  —  SUBJECTIVE  DISORDERS  OF  THE 
SPECIAL  SENSES  — TESTING  OF  CRANIAL 
NERVES.' 

THE  EYE. 

The  examination  of  the  eye  affords  indications  of  the 
greatest  variety  and  importance.  No  allusion  will  be  made 
here  to  diseases  of  the  eye  itself,  unless  in  so  far  as  these 
bear  on  general  symptomatology,  or  unless  they  might  lead 
to  confusion  or  error.  (For  Subjective  Disorders,  see  p. 
153.) 

The  yelloio  discoloration  of  the  conjunctiva  is  discussed 
elsewhere  in  connection  with  jaundice.  For  the  various 
points  bearing  on  the  diagnosis  of  jaundice,  and  the  color  of 
the  sclerotic,  see  Jaundice,  Chapter  xii. 

Opacities  of  the  cornea,  traces  of  old  iritis,  and  the  like, 
are  sometimes  useful  as  indicating,  along  with  notched  teeth 
and  other  signs,  certain  constitutional  affections,  especially 
syphilis  and  scrofula.  Acute  iritis  may  supervene  in  syphi- 
litic or  rheumatic  cases  while  under  observation. 

The  arcus  senilis  consists  of  an  opaque  ring,  or  segment 
of  a  ring,  in  thecornea  at  its  junction  with  the  sclerotic.  It 
usually  exists  in  both  eyes,  when  present  at  all,  but  it  may 
be  present  to  an  unequal  extent.     It  occurs  habitually  in 

1  In  addition  to  the  general  treatises  on  medicine,  those  on  Physi- 
ology also  must  be  consulted  for  details.  See  especially  Flint's 
Physiologii,  vol.  v.,  for  organs  of  sense. 

General  works  on  Nervous  Diseases  are  referred  to  in  the  next 
chapter.  Erb's  Treatise  on  the  peripheral  cerebro-spinal  nerves 
(Ziemssen's  Cyclopaedia,  vol.  xi.)  is  particularly  valuable  in  this 
connection. 

As  regards  the  Eye,  see  Soelberg  Wells,  Carter,  Mackenzie,  ^\\- 
bntt  on  Ophthalmoscopic  Examination  of  Medical  Cases,  and  Hugh- 
lings  Jackson's  papers  in  British  Medical  Journal,  1877,  vol  i. 

For  the  Ear,  consult  von  Troeltsch,  Roosa,  Dalby,  and  Hinton 
(in  Holmes's  System,  vol.  iii.). 


EYE.  129 

persons  over  60.  When  present  in  younger  subjects  (35  to 
50)  it  is  to  be  regarded  as  a  sign  of  early  degeneration  of 
the  tissues;  it  is  very  often  associated  with  atheroma,  gout, 
renal  disease,  and  cardio-vascular  changes. 

Suffusion  of  the  eyes,  with  injection  of  the  conjunctiva 
and  lachrymation,  is  often  due  to  local  causes;  but  we  also 
find  it  at  the  beginning  of  certain  fevers,  especially  measles 
and  typhus.  It  may  likewise  constitute  one  of  the  early 
signs  of  meningeal  and  cerebral  diseases. 

Protrusion  of  the  tchole  eyehcdl  (exophthalmos)  may  indi- 
cate abscess  of  the  orbit  or  tumor  somewhere  behind  the 
eyeball ;  in  such  cases  it  is  usually  unilateral.  When  it  af- 
i'ects  both  eyes,  and  Avhen  associated  with  enlargement  of  the 
thyroid,  and  rapidity  of  the  heart's  action,  it  constitutes  an 
important  feature  in  exophthalmic  goitre.  Considerable 
variation  exists  normally  in  the  prominence  of  the  eyeballs. 

Jnahility  to  close  the  eyelids  properly  (lagophthalmos)  is 
very  common,  but  not  invariable,  in  peripheral  paralysis  of 
the  facial  nerve.  (See  seventh  nerve,  p.  163.)  It  is  un- 
common, although  not  unknown,  in  the  paralysis  of  the  face 
of  ordinary  hemiplegia  from  cerebral  causes. 

Ptosis,  or  droop  of  the  upper  eyelid  is  a  sign  of  paralysis 
of  one  of  the  branches  of  the  third  nerve.  Sometimes,  how- 
ever, it  is  not  paralytic,  being  obviously  due  to  some  me- 
chanical impediment  in  the  action  of  the  muscles  or  eyelids 
themselves.  Wlien  paralytic  it  may  exist  alone,  or  be  com- 
bined with  other  evidence  of  a  lesion  of  this  nerve. 

Squinting,  or  Strabismus — Paralysis  of  the  Ocu- 
lar Muscles — Diplopia In  examining  for  strabismus 

we  get  the  patient  to  direct  his  vision  to  a  point  placed  ex- 
actly opposite  him  in  the  middle  line.  The  observer's  finger 
held  in  such  a  position  suits  quite  well.  This  is  tried  at 
various  distances,  both  near  and  remote,  and  we  notice 
whether  the  centre  of  the  cornea  coincides  with  the  centre 
of  the  palpebral  fissure.  If  a  deviation  occurs  (primaiy  de- 
viation), we  should  notice  whether  this  comes  into  more 
prominence  when  near  or  when  distant  objects  are  looked 
at;  we  also  observe  whether  the  eyeball  is  turned  inwards 
(internal  or  convergent  strabismus),  or  whether  it  is  turned 
outwards  (external  or  divergent  strabismus) ;  Ave  can  usually 
say  at  once  which  of  the  two  eyes  is  the  one  whose  axis  of 
vision  is  directed  to  the  object,  and  which  is  the  one  that 
deviates.  Sometimes,  however,  the  patient  can  fix  on  the 
object  with  either  eye  inditferently,  and  so  either  the  one  or 


130  ORGANS  OF  SPECIAL  SENSE. 

the  other  may  deviate  ("alternate  squint").  When  the 
same  eye  is  always  used  to  fix  on  the  object  there  is  usually 
a  distinct  diifereuce  in  the  acuteness  of  the  vision  on  the 
two  sides — the  better  eye  being  of"  course  selected  by  the 
patient  for  this  purpose.  If  now  we  get  the  patient  to  fix  on 
the  object  with  the  less  perfect  eye,  by  interposing  the  hand 
before  the  sound  one,  or  by  placing  a  piece  of  dimmed  glass 
in  front  of  it,  we  may  then  find  that  the  sound  eye  (which 
was  quite  straight  in  the  former  experiment)  deviates  inwards 
or  outwards,  just  as  the  other  did.  In  many  cases  this 
"secondary  deviation,"  as  it  is  called,  can  be  ascertained, 
by  a  scale  placed  below  the  eyelid,  to  be  exactly  equal  to 
the  primary  deviation ;  this  is  the  common  case  when  the 
squint  depends  on  hypermetropia  and  myopia  apart  from  any 
paralysis  of  the  ocular  muscles  ("concomitant  squint");  in 
paralytic  squint  the  secondary  deviation  is  often  more  ex- 
treme than  the  primary,  and  this  sometimes  constitutes  an 
important  indication  of  ocular  paralysis.  A  deviation,  how- 
ever, which  originated  in  a  paralysis  may  be  perpetuated  as 
a  concomitant  squint  after  the  paralysis  has  passed  away; 
and  in  rare  cases,  from  the  persistence  of  a  non-paralytic 
squint,  and  the  stretching  of  the  fibres  of  the  muscle,  we  may 
find  a  want  of  proper  movement  from  simple  muscular  Aveak- 
ness  apart  from  any  true  paralysis. 

In  cases  of  "  concomitant  squinf''  there  is  no  impairment 
of  the  movement  of  the  eyeballs,  and  this  can  be  shown,  by 
testing  the  eyes  separately — one  only  being  open  at  a  time, 
and  the  object  looked  at  being  carried  up  and  down,  and  to 
the  extreme  right  and  left ;  the  free  mobility  of  each  eye  in 
all  directions  may  then  be  ascertained.  Strabismus  having 
these  peculiarities  depends  on  a  want  of  proper  adjustment 
in  the  action  of  the  muscles,  or  on  a  certain  shortening  of 
one  or  other  of  them  ;  such  a  squint  depends,  in  the  great 
majoi'ity  of  cases,  on  errors  in  the  refraction  of  the  eye, 
convergent  squint  being  associated  with  hypermetropia,  and 
divergent  squint  with  myopia.  These  errors  in  refraction 
are  in  many  cases  hereditary,  so  that  a  tendency  to  squinting 
may  be  inherited.  In  such  cases  of  strabismus,  binocular  or 
stereoscopic  vision  is  usually  sacrificed  at  an  early  period  in 
the  case,  and  so  the  patient  is  not  troubled  with  diplopia. 
Specks  on  the  cornea,  and  other  defects  in  the  vision  often 
seem  to  determine  the  occurrence  of  squinting  and  the  sup- 
pression of  the  weak  eye.  Patients  with  hypermetropia  and 
myopia  may  also  have  squinting  produced  by  various  acute 


EYE— SQUINTING.  131 

illnesses  of  a  general  nature ;  this  squint  may  be  temporary 
or  permanent.  It  may  thus  simulate  a  cerebral  disturbance 
under  certain  circumstances. 

In  paralytic  squint  the  movement  of  the  eyeball  is  im- 
paired in  certain  directions,  so  that  it  cannot  be  moved  out- 
wards or  inwards  beyond  the  middle  line,  as  the  case  may 
be  ;  the  sound  muscle,  moreover,  overbalances  the  paralyzed 
one,  so  that,  for  example,  in  paralysis  of  the  external  rectus 
we  have  often  an  internal  squint,  and  in  paralysis  of  the 
internal  rectus  an  external  squint.  Before  concluding  that 
there  is  ocular  paralysis,  we  must  see  that  no  merely  me- 
chanical impediment  exists  to  hinder  the  movements.  In 
paralytic  squint  the  "  secondary  deviation"  already  described 
is  often  greater  than  the  primary,  and  when  the  vision  is 
directed  towards  the  paralyzed  muscle,  this  is  often  very 
extreme.  Thus,  if  a  person  with  paralysis  of  the  right  ex- 
ternal rectus  be  tested  as  to  his  affected  eye  (the  vision  of 
the  other  being  obstructed  with  a  dimmed  glass),  and  if  he 
be  directed  to  look  at  an  object  at  his  extreme  right,  the 
nervous  energy  is  directed  to  the  rigid  external  rectus  and 
to  the  left  internal  rectus,  so  as  to  execute  this  conjoint 
movement ;  as  the  paralyzed  muscle  does  not  respond  pro- 
perly, a  still  furtlier  force  is  directed  to  these  muscles,  and 
thus  the  internal  rectus  of  the  sonnd  eye  is  led  to  contract 
excessively,  and  quite  beyond  anything  that  is  required  ;  its 
pupil  may,  indeed,  be  buried  within  the  palpebral  fissure. 

Diplopia  is  a  common  feature  in  paralytic  squint ;  indeed, 
diplopia  may  constitute  the  only  evidence  of  a  slight  paralysis 
of  an  ocular  muscle  ;  for  when  this  "  paresis,"  as  it  is  called, 
is  slight,  there  may  be  no  discernible  diminution  of  the 
movements  of  the  eyeball.  Diplopia  is  usually  complayied 
of  by  patients  when  it  is  present  to  any  marked  extent,  but 
it  is  sometimes  slight,  or  only  developed  in  certain  directions 
of  the  vision.  Moreover,  it  is  often  important  to  determine 
the  relsition  of  the  two  images  to  the  respective  eyes,  and  so 
a  careful  test  is  often  demanded.  A  candle  in  a  dark  room, 
placed  at  different  heights,  and  in  diffei-ent  positions  to  the 
right  or  left  of  the  patient,  may  be  used.  It  is  well  also  to 
have  a  piece  of  red  glass  to  place  before  one  of  the  eyes,  so 
as  to  identify  each  image  by  its  color.  If  the  vision  of  one 
of  the  eyes  is  less  perfect  than  the  other,  we  place  the  colored 
glass  before  the  sound  eye,  so  as  to  render  the  defective  im- 
age relatively  plainer.  The  faulty  image  is  usually  recog- 
nized, apart  from  this  contrivance,  by  a  certain  dimness  or 


132  ORGANS    OF    SPECIAL    SENSE. 

obscurity  as  compared  with  the  other  ;  the  false  image  may 
be  placed  at  the  side  of  the  other,  or  above  or  below  it,  or 
there  may  be  an  obliquity  in  its  position  ;  these  differences 
depend  on  the  affection  being  due  to  pai'alysis  of  the  superior, 
inferior,  external,  or  internal  recti  muscles,  or  of  the  superior 
or  inferior  oblique,  or  to  various  combinations  of  these  para- 
lytic lesions. 

With  regard  to  lateral  displacement  of  the  false  image, 
we  must  ascertain  whether  the  diplopia  is  "  crossed"  or 
*'  direct."  If  with  the  assistance  of  the  colored  glass  the 
image  to  the  rigid  be  found  to  be  that  which  is  seen  with  the 
right  eye,  then  we  call  the  diplopia  "  direct"  or  "  homony- 
mous." If  with  the  same  test  we  find  that  the  image  iden- 
tified with  the  right  eye  is  seen  to  the  left,  then  we  call  it 
*'  crossed."  "  Crossed"  diplopia  occurs  in  paralytic  dither- 
gent  squint,  or  Avhen  there  is  a  tendency  to  it ;  "  direct" 
diplopia  occurs  when  there  is  a  tendency  to  convergence. 

The  images  may  also  be  superimposed,  the  one  above  the 
other,  and  this  is  usually  associated  with  a  certain  obliquity 
in  the  position  of  the  imase  seen  by  the  paralyzed  eye ;  this 
may  be  slightly  "  crossed"  or  not  in  different  cases. 

In  order  to  facilitate  the  investigation  of  these  varieties  of 
paralysis  the  following  details  are  submitted  in  a  tabular 
form  : — 

FUNCTIONS  OF  OCULAR  MUSCLES. 

Eectus  superior  elevates  and  slightly  inverts  the  eye. 
Obliquus  inferior^  elevates  and  slightly  everts  the  eye. 
Rectus  inferior  depresses  and  slightly  inverts  the  eye. 
Obliquus  superior^  depresses  and  slightly  everts  the  eye. 
Rectus  internus  inverts  the  eye. 
Rectus  esternus  everts  the  eye. 

Hence  we  find  that  the  position  of  the  eye  or  of  the  pupil 
varies  according  to  the  special  muscle  paralyzed,  when  the 
paralysis  is  of  such  a  degree  as  to  give  rise  to  deviation, 
although,  as  already  explained,  diplopia  may  be  the  only 
evidence  of  a  slight  paresis.  Moreover,  as  this  deviation 
depends  on  the  activity  of  the  sound  muscles  quite  as  much 
as  on  the  Aveakness  of  the  paralyzed  one,  the  results  are  not 
always  uniform,  as  we  may  have  to  deal  with  a  double  or  a 

'  The  Rectus  superior  and  the  Obliquus  inferior  are  thus  required 
jointly  for  a  pure  elevation. 

2  The  Rectus  inferior  and  the  Obliquus  superior  are  thus  re- 
quired jointly  for  a  pure  depression. 


DIPLOPIA    IN    OCULAR    PARALYSIS.  133 

complex  paralysis.     In  the  following  tabular  statement  only 
one   muscle  is  presumed  to  be  atlected,  the  rest  being  sound. 

RESULTS  OF  PARALYSIS  OF  SPECIAL  OCULAR 
MUSCLES   WHEX  THE  OTHERS  ARE  SOUXD. 

Paralysis  of  Rectus  Superior :  inability  to  raise  eyeball  properly 
above  horizontal  level ;  pupil  may  diverge  somewhat  down- 
vrards,  and  a  little  outwards  (from  action  of  the  rectus  inferior 
and  the  obliqui). 

Paralysis  of  Rectus  Inferior  :  inability  to  lower  eyeball  properly 
below  horizontal  level ;  pupil  may  diverge  somewhat  upwards, 
and  a  little  outwards  (from  action  of  the  rectus  superior  and 
the  obliqui). 

Paralysis  of  Rectus  Externus  :  inability  to  turn  eyeball  properly 
outwards  ;  pupil  diverges  inwards  (from  action  of  rectus  in- 
ternus). 

Paralysis  of  Rectus  Internus  ;  inability  to  turn  eyeball  properly 
inwards  ;  pupil  diverges  outwards  (from  action  of  rectus  ex- 
ternus). 

Paralysis  of  Obliqnus  Superior :  but  little  alternation  in  move- 
ments of  eyeball ;  slight  deviation  of  cornea  upwards  and  in- 
wards, or  simply  upwards. 

Paralysis  of  Obliquus  Inferior  :  but  little  alteration  in  movements 
of  the  eyeball  ;  slight  deviation  of  the  cornea  downwards  and 
inwards.  (Paralysis  of  the  sphincter  of  the  iris,  giving  rise 
to  a  moderate  dilatation  of  the  pupil,  and  to  paralysis  of  the 
accommodation,  often  accompanies  this  form  of  paralysis  ;  this 
depends  on  the  branch  to  the  lenticular  ganglion  being  given 
off  from  that  branch  of  the  third  nerve  which  goes  to  the  in- 
ferior oblique  muscle.  Occasionally,  however,  this  lenticular 
branch  arises  from  the  sixth  nerve). 

DIPLOPIA  IX  OCULAR  PARALYSIS. 

Diplopia  is  specially,  or  perhaps  only,  developed  when  the 
vision  is  directed  towards  the  paralyzed  muscle,  or  in  the 
direction  in  which  its  action  should  be  called  into  play  :  thus, 
upwards  when  the  elevators  are  paralyzed,  downwards  when 
the  depressors  are  involved,  and  outwards  or  inwards  in  the 
case  of  the  external  and  internal  recti.  Certain  actions,  as 
climbing  or  descending  a  ladder,  may  thus  bring  a  diplopia 
into  troublesome  prominence  ;  on  the  other  hand,  a  certain 
position  of  the  head  is  often  assumed  by  the  patient  so  as  to 
prevent  the  tendency  to  diplopia.  In  testing,  therefore,  we 
require  to  use  various  positions  for  the  object. 

The  following  points  being  borne  in  mind,  may  help  us  to 
understand  the  variations  in  diplopia : — When  the  tendency 
12 


134  ORGANS    OP    SPECIAL    SENSE. 

is  to  divergent  squint,  the  diplopia  is  "  crossed."  When  tlie 
tendency  is  to  convergent  squint,  the  diplopia  is  "  direct" 
(homonymous). 

The  superior  and  inferior  recti,  as  already  mentioned,  tend 
to  draw  the  eyeball  somewhat  inwards,  when  their  correctors 
Jire  paralyzed.  The  two  obliqui  tend  to  evert  the  eyeball 
when  the  counter-balancing  muscles  are  paralyzed. 

External  Rectus  Paralyzed  :  diplopia  is  "  direct ;"  images  on  same 
level ;  displacement  increased  by  moving  the  object  outwards. 

Internal  Rectus  Paralyzed  :  diplopia  is  "  crossed  ;"  images  on  same 
level ;  disi)lacement  increased  by  moving  the  object  towards 
the  sound  side. 

Superior  Rectus  Paralyzed:  diplopia  vertical  and  "crossed  ;"  image 
seen  by  faulty  eye  above  the  other,  and  somewhat  obliquely, 
chiefly  when  vision  is  directed  upwards. 

Inferior  Rectus  Paralyzed  :  diplopia  vertical  and  "crossed  ;"  image 
seen  by  faulty  eye  below  the  other,  and  somewhat  obliquely, 
chiefly  when  vision  is  directed  downwards. 

Superior  Oblique  Paralyzed  :  diplopia  vertical  and  not  "  crossed  ;" 
image  seen  by  faulty  eye  below  the  other,  and  somewhat  ob- 
liquely, chiefly  when  vision  is  directed  downwards. 

Inferior  Oblique  Paralyzed  :  diplopia  vertical  and  not  "  crossed  ;" 
image  seen  by  faulty  eye  above  the  other,  and  somewhat  ob- 
liquely, chiefly  when  vision  is  directed  upwards. 

The  Clinical  Significance  of  Squint  and  Ocular  Paralysis. 
■ — When  a  squint  is  not  of  paralytic  origin  it  has  not  much 
significance  to  the  physician.  Occasionally  a  squint  origi- 
nates in  a  paralysis,  although  this  may  have  passed  quite 
away ;  in  such  a. case  it  has  some  significance  in  the  history. 
But  it  must  also  be  remembered  that  in  subjects  predisposed 
to  strabismus  by  optical  defects,  a  concomitant  squint  may 
originate  in  connection  with  any  acute  illness  quite  apart 
from  paralysis. 

When  a  squint  is  due  to  paralysis  of  the  third,  fourth,  or 
sixth  nerves  (see  pp.  161,  162)  it  has  great  significance.  As 
a  rule  these  nerves  are  affected  by  lesions  at  the  base  of  the 
brain,  or  the  base  of  the  skull,  so  that  some  intei-ference  with 
the  nerve  itself  m  its  course  \s  indicated,  rather  than  a  lesion 
at  its  deep  origin  ;  the  lesion  is  thus  on  the  same  side  as  the 
paralyzed  muscle.  Hence  these  nerves  are  specially  involved 
in  cases  of  cerebral  tumor  and  basal  meningitis  ;  they  are  all 
very  frequently  paralyzed  from  sypliilitic  disease  witliin  the 
skull.  When  one  of  these  nerves  is  involved,  the  other  cra- 
nial nerves  must  also  be  examined,  as  combinations  of  paral- 
ysis of  the  sixth  nerve  with  patches  of  ana3sthesia  in  the 
region  of  the  fifth,  for  example,  are  even  more  suggestive  of 


EQUALITY    OR    INEQUALITY    OF    THE    PUPILS,       135 

syphilitic  lesions.  Paralysis  of  the  fourth  nerve  is  usually 
due  to  syphilis.  Paralysis  of  these  three  nerves,  however, 
and  especially  of  the  third,  may  often  be  classified  with  the 
so  called  "  rheumatic"  paralyses :  that  is,  they  seem  to  be 
induced  by  cold. 

Paralysis  of  the  third  nerve  when  complete,  includes  droop 
of  the  upper  eyelid  (ptosis),  paralysis  of  all  the  muscles  of 
the  eyeball  except  the  external  rectus  and  the  superior  ob- 
lique, dilatation  of  the  pupil,  and  some  defect  in  the  power 
of  accommodation.  Tliis  paralysis  of  most  of  the  muscles 
leads  to  great  deficiency  in  the  mobility  of  the  eye,  as  already 
explained,  and  the  pupil  is  directed  outwards  and  somewhat 
downwards.  The  paralysis  of  the  sphincter  of  the  iris  should 
be  specially  studied  in  connection  with  the  signs  of  paralysis 
of  the  inferior  oblique  muscle  (occasionally,  however,  this 
supply  to  the  iris  comes  from  the  sixth  nerve.)  The  dilata- 
tion of  the  pupil  in  paralysis  of  the  third  nerve  is  moderate: 
it  can  be  rendered  much  more  extreme  by  the  use  of  atropine. 
Extreme  dilatation  of  the  pupil,  therefore,  may  indicate  some 
irritation  of  the  sympathetic,  when  there  is  no  question  of 
the  use  of  atropine  or  belladonna.  The  various  branches  of 
the  third  nerve  may  be  paralyzed  separately,  so  that  we  may 
have  ptosis  alone,  or  external  deviation  alone,  or  dilatation  of 
the  pupil,  or  various  combinations  up  to  the  most  complete  pa- 
ralysis of  the  nerve. 

Equality    or    Inequality   of  the    Pupils Normally   the 

pupils  are  equal :  they  dilate  considerably  in  the  dark  and 
contract  when  exposed  to  natural  or  artificial  light.  Occa- 
sionally, however,  the  pupils  are  unequal  congenitally,  and 
the  response  to  light  diminished  in  the  eye  whose  pupil  is 
already  contracted  (congenital  myosis).  In  examining  such 
cases  we  should  do  so  while  they  are  shaded  from  any  bright 
light.  Inequality  of  the  pupils  is  occasionally  found  in  some 
persons  (congenitally  ?)  along  with  other  indications  of  an 
affection  of  the  sympathetic,  such  as  unilateral  sweatings. 
Old  iritis  sometimes  accounts  for  the  contraction  and  immo- 
bility of  the  pupil  observed  :  this  can  usually  be  made  out  by 
detecting  traces  of  exudation,  or  some  irregularity  in  the  out- 
line of  the  iris,  especially  on  dilatation  with  atropine.  As 
iridectomy  is  now  so  common,  the  student  must  learn  to  rec- 
ognize an  artificial  pupil.  The  possibility  of  an  eye  wash 
containing  belladonna  or  atropine  being  used  must  never  be 
forgotten  in  the  inquiry :  occasionally  a  little  of  some  bella- 
donna liniment  gets  into  an  eye  quite  accidentally.     The 


136  ORGANS    OF    SPECIAL    SENSE. 

action  of  belladonna  in  dilating,  or  of  Calabar  bean  in  con- 
tracting, an  abnormal  looking  pupil,  sometimes  affords  assist- 
ance in  the  estimation  of  the  abnormality. 

Apart  from  these  circumstances,  inequality  of  the  pupils  is 
ahvays  a  fact  of  great  importance  as  indicating,  1st,  (in 
cases  of  dilatation),  some  lesions  of  the  third  nerve,  the  sig- 
nificance of  which  must  be  estimated  by  considering  whether 
the  other  branches  of  this  nerve  are  involved.  Irritation  of 
the  sympathetic  (as  distinguished  from  paralysis)  may  like- 
wise lead  to  dilatation  of  the  pupil.  In  cases  of  this  kind 
we  must  search  ibr  evidence  of  disturbance  of  the  sympa- 
thetic, and  see  whether  the  other  cranial  nerves  are  affected. 
2d,  Abnormal  contraction,  that  is,  the  absence  of  any  con- 
siderable dilatation  when  shaded  from  the  light,  may  be  due 
to  some  affection  of  the  sympathetic  in  the  neck,  or  of  the 
cervical  spinal  cord  (spinal  myosis,  idiopathic  affection  or- 
wounds  of,  or  pressure  on,  the  sympathetic  in  the  neck  from 
tumors,  especially  from  aneurisms ;  and  perhaps  general 
paralysis  of  the  insane).  3d,  The  inequality  may  be  due  to 
some  unilateral  lesion  of  the  brain,  or  perhaps  to  une'qual 
pressure  of  fluid  on  the  two  sides  of  the  brain  in  cases  of 
injury  or  effusion.  Even  when  due  to  serious  disease  the 
inequality  does  not  always  preserve  the  same  degree,  and 
indeed  is  not  always  persistent. 

Alterations  in  the  size  of  both  pupils  are  likewise  import- 
ant. Sometimes  they  are  unduly  dilated  or  contracted,  and 
sometimes  they  fail  to  respond  to  the  light  in  the  usual  way. 
Contraction  of  the  pupils  may  be  produced  by  the  use  of 
opium,  and  this  affords  a  valuable  means  of  diagnosis  in 
cases  of  suspected  opium  poisoning,  and  also  in  estimating 
the  effect  which  0})ium,  as  a  medicine,  may  have  had  on  the 
system.  Belladonna  and  atropine,  administered  internally 
or  absorbed  through  the  skin  or  mucous  surfaces,  as  well  as 
applied  to  the  eye  and  brow,  produce  well-marked  dilatation 
of  the  pupil  :  if  applied  to  one  eye  they  act  only  on  one  side. 
Calabar  bean,  applied  to  the  eye  or  given  internally,  causes 
well-marked  contraction.  Atropine  and  Calabar  bean  seem 
to  have  a  special  and  direct  stimulating  influence  on  the 
radiating  and  circular  fibres  of  the  iris,  respectively,  in  ad- 
dition to  any  paralyzing  effect  on  the  nervous  supply.  Alco- 
hol and  chloro!brm  likewise  affect  the  pupil,  but  in  rather  an 
uncertain  way,  due  in  [art,  perhaps,  to  their  dose,  and  to 
their  varying  effect  on  the  system  :  other  agents  also  have  at 
times  an  action  on  the  pupil.     In  cerebral  diseases  the  pupils 


STATE    OF    THE    PUPILS,  13Y 

are  often  unduly  contracted  or  dilated,  but  it  is  scarcely 
possible,  in  the  present  state  of  our  knowledge,  to  lay  down 
any  general  doctrine  on  the  subject.  In  simple  serous  effu- 
sion, in  meningitis  with  effusion,  and  in  many  cases  of  apo- 
plexy, the  pupils  are  dilated  (pressure  signs).  In  not  a  few 
cases  of  apoplexy,  however,  the  pupils  are  contracted,  and 
this  is  seen  in  some  of  the  worst  and  most  rapidly  fatal  forms 
of  hemorrhage  (in  the  pons).  In  epileptic  fits  the  pupils  are 
often  contracted  during  the  fit  and  dilated  after  it.  The 
student  must  content  himself  with  noting  the  state  of  the 
pupils,  reserving  the  significance  of  the  sign  for  further  con- 
sideration and  study  in  view  of  the  whole  facts.  In  cases 
of  total  blindness  of  both  eyes  the  pupils  are  permanently 
dilated,  unless,  indeed  there  be  adhesion  of  the  iris.  In 
uremic  poisoning  (renal  disease)  and  in  typhus  fever,  espe- 
cially in  the  stage  of  delirium,  the  pupils  are  usually  con- 
tracted :  in  enteric  fever  on  the  other  hand,  the  pupils  are 
rather  dilated.  During  natural  sleep  the  pupils  are  con- 
tracted:  this  can  often  be  seen  by  gently  raising  the  eyelid;' 
the  pupil  then  dilates  as  the  person  awakes,  and,  if  the  light 
be  bright,  contracts  .again  under  this  -stimulus.  Under 
moderate  doses  of  chloral  tlie  behavior  is  the  same  as  in 
natural  sleep. 

The  sensitiveness  of  the  pvpils  to  light  should  be  tested 
by  first  covering  the  eyes  with  the  eyelids  and  fingers,  and 
then  opening  them  suddenly ;  or  by  keeping  the  lids  open 
and  shading  the  eyes  from  the  light  and  suddenly  exposing 
them  again  ;  tlie  degree  and  rapidity  of  dilatation  and  con-, 
traction  may  be  thus  observed.  Artificial  light  from  a  taper 
or  candle  often  suits  better  than  dayliglit,  as  its  direction  is 
moie  under  control.  The  test  is  sometimes  applied  to  dis- 
cover the  sensitiveness  of  the  retina  in  those  who  are  uncon- 
scious or  unable  to  express  themselves.  In  such  cases  we 
may  have  contraction  of  the  iris  in  a  blind  eye  through  the 
influence  of  light  on  the  other,  if  it  be  sensitive,  and  there 
may  be  likewise  a  sympathetic  dilatation  :  hence  it  is  better 
to  test  the  eyes  separately.  The  sensitiveness  of  the  pupil 
to  light  is  often  much  diminished  in  apoplexy,  and  also  when 
there  is  effusion  of  any  kind  on  the  brain.  In  some  casds  of 
meningitis  the  pupil  is  affected  by  light,  but  instead  of  con- 
tracting it  oscillates,  i.  e.,  varies  between  contraction  and 
dilatation  in  a  curious  way.  (Tremulousness  of  the  iris  itself, 
backwards  and  forwards  with  a  wave-like  motion,  arises  from 
undue  fluidity  of  the  vitreous,  probably  combined  with  rup- 

12* 


138  ORGANS    OF    SPECIAL    SENSE. 

ture  of  some  portion  of  the  ligament  of  the  lens,  and  is  only 
of  ophthalmic  interest.)  When  one  or  both  pupils  are  much 
dilated  or  contracted  from  the  influence  of  drugs,  or  from 
paralysis,  or  from  congenital  peculiarity,  they  are  not  readily 
affected  by  light. 

Convulsive  movenients  of  the  occular  and  pal-pehral  mus- 
cles exist  as  independent  functional  affections  of  the  eye  ; 
they  then  come  more  properly  under  the  notice  of  ophthal- 
mic surgeons,  but  they  sometimes  serve  to  indicate  cerebral 
mischief.  Spasm  of  the  orbicularis  palpebrarum  (blepha- 
rospasm) occurs  in  cases  of  intolerance  of  light,  and  also 
from  other  forms  of  reflex  irritation,  but  twitchings  and  re- 
mittent spasm  of  this  muscle  may,  if  severe,  be  due  to  more 
general  and  central  causes,  resembling  thus  certain  forms  of 
wry-neck,  twitchings  of  the  trapezius,  &c. 

Nystagmus  (convulsive  rhythmical  movement  of  the  eye- 
ball) occurring  as  an  independent  affection,  and  dating  from 
early  life,  need  not  be  noticed  here.  Nystagmus  seems  also 
to  be  developed  in  connection  with  particular  occupations,  as 
in  coal  miners  and  some  others.  It  is  also,  however,  met 
with  as  a  symptom  of  a  definite  and  localized  disease  of  the 
nervous  centres  ;  it  sometimes  appears  in  one  eye  only,  but 
usually  in  both.  The  movements  can  often  be  seen  at  the 
beginning  of  fits,  and  are  then  regarded  as  part  of  the  con- 
vulsion. Sometimes,  however,  they  are  associated  with  a 
peculiar  deviation  of  the  eyes,  both  eyes  being  directed  as 
if  the  patient  were  trying  to  look  fixedly  towards  the  back 
of  his  shoulder  (conjugate  or  lateral  deviation  of  the  eyes)  ; 
associated  with  tliis  there  is  often,  if  not  usually,  a  turning 
of  the  head  also  in  the  same  direction.  This  group  of  symp- 
toms seems  to  be  associated  with  disease  affecting  the  crura 
cerebri,  and  the  head  and  eyes  are  turned  to  the  side  on 
which  the  disease  exists  in  tlie  brain,  viz.,  away  from  the 
paralyzed  limbs  in  cases  in  which  paralysis  exists. 

llie  acuteness  of  vision  affords  indications  as  to  the  state 
of  the  optic  nerve,  but  of  course  the  vision  may  be  inter- 
fered with  by  many  local  causes  which  have  no  special  sig- 
nificance to  the  physician  (opacity  of  the  media,  closed  )>upil, 
&c.-)  ;  moreover,  the  advance  of  age  lessens  and  abolishes 
the  power  of  accommodation  (presbyopia),  and  there  may 
also  be  a  paralysis  of  the  accommodation  from  nervous 
lesions  or  the  action  of  drugs.  Optical  defects  (hyperme- 
tropia,  myopia,  and  astigmatism)  often  produce  imperfect 
vision,   and  so  may  simulate   an   impairment  of   the    optic 


FIELD    OF    VISION.  139 

nerve.  These  subjects  must  be  studied  in  detail  tit  the^eye 
infirmaries,  but  with  a  few  precautions  the  use  of  Snellen's 
test-types^  affords  a  valuable  means  of  testing  the  vision  : 
the  different  numbers  of  his  scale  can  be  read  fluently  by  an 
average  eye  at  the  corresponding  number  of  feet^  (No.  1^ 
at  a  foot  and  half,  No.  20  at  20  feet,  &c.)  ;  lines  and  spots 
are  given  which  may  be  counted  by  those  who  are  unable  to 
spell  the  Eoman  capitals.  In  using  the  types  both  high  and 
low  numbers  should  be  used  at  corresponding  distances.  The 
difference  between  the  nearest  and  furthest  points  at  which 
the  smaller  types  can  be  read  indicates  the  range  of  the 
accommodation  ;  but  a  full  examination  demands  in  certain 
cases  the  use  of  lenses  also. 

The  degree  of  hypermetropia  is  estimated  by  the  strongest 
convex  glass  with  which  the  person  can  read  No.  20  at  20 
feet,  or  the  corresponding  types  at  6  metres :  this  represents 
the  "manifest  hypermetropia."  But  when  the  accommoda- 
tion is  completely  paralyzed  by  the  repeated  a]>plication  of 
atropine,  a  further  strength  of  convex  lens  may  be  required, 
this  addition  being  the  index  of  the  "latent  hypermetropia." 
In  the  case  of  myopia  the  weakest  concave  glass  sufficient  to 
render  No.  20  visible  at  20  i'eet  (or  at  6  metres)  is  reckoned 
the  measure  of  the  myopia.  When  such  lenses  improve  the 
vision  without  rendering  it  perfect,  astigmatism  should  be 
tested  for:  some  circular  arrangement  may  be  used,  such  as 
the  dial  of  a  clock,  to  see  if  all  the  figures  on  the  circle  and 
the  hands  in  the  various  positions  are  perfectly  straight  and 
equally  distinct.  When  by  suitable  glasses  the  person  can 
read  No.  20  at  20  I'eet  (or  at  6  metres  in  the  other  scale), 
we  reckon  the  vision  good,  the  presumption  being  that  any 
defects  are  merely  due  to  optical  causes.  In  many  such 
cases,  however,  the  correction  is  not  absolutely  satisfactory, 
especially  in  myopia. 

It  must  he  remembered  that  there  may  he  a  marked  affec- 
tion of  the  optic  nerve  although  the  jjerson  may  he  u  le  to 
read  the  smallest  types  quite  satisfactorily. 

'  Test-Types  for  the  Determination  of  the  Acuteness  of  Vision,  by 
H.  Snellen,  M.D.,  Fourth  Edition.  Williams &Norgate,  1868.  Also, 
Optotypi  ad  Visum  Determinandum.  Editio  Quinta.  Metrico  Sys- 
temate.     1875. 

2  Parisian  feet  which  are  slightly  longer  than  English  ;  propor- 
tion, 4G-49. 

In  the  fifth  edition  the  metrical  system  is  followed,  beginning  at 
0.5,  0.6.  and  so  on  in  fractions  of  a  metre. 


140  ORGANS    OF    SPECIAL    SENSE. 

The  field  of  vision  should  be  estimated  in  certain  cases,  as 
it  is  often  of  great  importance  in  medical  practice:  it  is  found 
to  be  much  diminished  in  some  aifections  of  the  optic  nerve, 
due  to  cerebral  as  well  as  to  more  local  causes.  Each  eye 
should  be  tested  separately :  the  line  of  vision  of  the  patient 
is  to  be  directed  steadily  forwards,  say  to  the  nose  of  the 
observer  seated  immediately  opposite  him,  and  the  observer's 
finger  or  some  luminous  object  in  his  hand  should  then  be 
carried  to  the  extreme  left  and  right,  and  above  and  below, 
till  the  limit  is  reached  at  which  it  is  still  visible  while  the 
eye  is  kept  looking  straight  forward.  Ophthalmic  surgeons 
have  more  accurate  methods  of  measuring  and  reducing  to  a 
scale  the  field  of  vision,  but  this  method  is  a  ready  means  of 
forminof  a  fair  o-eneral  estimate.  The  field  of  vision  is  some- 
times  contracted  almost  equally  in  all  directions,  but  the 
defect  is  usually  in  particular  directions,  such,  for  example, 
as  the  upper  and  inner  half.  When  the  defect  is  strictly 
defined  as  being  to  one  half,  usually  a  lateral  half,  the  affec- 
tion is  named  Hemiopia  (see  p.  156).  Local  defects  in  the 
field  of  vision  may  be  detected  in  connection  with  localized 
lesions  of  the  retina. 

Ophthalmoscopic  examination  of  the  eye  is  useful  (1)  in 
discovering  whether  the  loss  of  vision,  which  may  be  de- 
tected, is  due  to  other  than  nervous  lesions  ;  (2)  in  distin- 
guishing various  affections  of  the  retina  and  optic  nerve 
from  each  other ;  and  further,  (3)  marked  changes  of  much 
diagnostic  significance  are  sometimes  discovered  when  there 
is  no  affection  of  the  vision  as  tested  by  types.  The  use  of 
the  ophthalmoscope  must  be  learned  practically  in  the  dark 
rooms  of  our  eye  infirmaries,  and  no  description  of  the  in- 
struments or  the  methods  of  using  them  would  be  here  of 
much  use.  The  methods  by  the  erect  and  inverted  images 
are  both  used  for  medical  cases,  but  for  the  more  delicate 
examination  of  the  nervous  and  vascular  changes  the  direct 
metliod  is  preferable.  The  student  should  aim  at  making 
himself  familiar  with  both  methods,  and  should,  by  examin- 
ing many  eyes,  apart  from  any  cerebral  affections,  learn  to 
distinguish  the  varieties  in  the  size,  shape,  and  appearance 
presented  by  the  optic  nerve,  whether  congenital  or  acquired, 
and  in  particular  the  changes  in  the  fundus  so  often  asso- 
ciated with  hypermetropia  and  myopia.  He  should  also 
learn,  if  possible,  to  estimate  the  degree  of  hypermetropia  or 
myopia  by  means  of  the  opthalmoscope,  as  in  many  cases  in 
■medical  practice  no  other  method  is  available. 


OPHTHALMOSCOPIC    APPEARANCES.  141 

The  following  ai'e  the  points  specially  to  be  attended  to  in 
using  the  ophthalmoscope  in  medical  cases:  TJie  shape  of 
the  optic  disc  should  be  noted;  if  both  discs  are  oval  in  the 
same  direction,  instead  of  being  circular,  optical  delects 
(astigmatism)  should  be  tested  for,  before  concluding  that 
there  is  a  real  change.  The  course  of  the  bloodvessels  over 
the  disc  must  be  scrutinized;  in  particular  let  it  be  noted 
Avhether  the  arteries  appear  to  project  forward  on  the  disc, 
or  to  curve  over  its  edge  from  its  swollen  state  (choked  disc, 
(Edematous  papilla).  The  size  and  appearance  of  the  large 
arteries  should  be  described,  as  to  whether  they  seem  dimin- 
ished in  calibre,  and  whether  they  appear  glistening  and  as 
if  affected  with  sclerosis,  or  accompanied  with  whitish  streaks. 
These  streaks  are  found  associated  both  with  intra-ocular 
and  with  cerebral  disturbances:  in  the  former  (hypermetro- 
pia)  the  acuteness  of  vision  is  not  diminished,  but  in  cere- 
bral cases  giving  rise  to  this  condition  of  the  arteries,  the 
vision  is  almost  always  affected ;  streaks  over  the  centre  of 
the  vessels  do  not  indicate  serious  changes,  and  are  due 
probably  to  mere  reflection  of  the  light.  The  vessels  may 
be  abolished  by  an  emholism  of  the  retinal  artery  or  of  one 
of  its  branches ;  this  accident  is  characterized  by  sudden 
blindness;  at  first  there  is  a  whitish  patch  of  exudation  with 
a  red  spot,  marking  the  position  of  the  macula ;  this  exuda- 
tion disappears,  and  the  color  returns  in  a  few  days,  but  the 
vessels  soon  become  obliterated,  and  the  blindness  is  perma- 
nent, llie  veins  should  be  noted  as  to  the  presence  of  en- 
largement or  tortuosity,  and  as  to  whether  they  seem  spe- 
cially dark  and  congested  where  they  dip  into  the  tissue  of 
the  nerve.  The  size  and  color  of  the  disc  are  very  impor- 
tant: attention  must  be  directed  to  see  if  it  is  unduly  pale  or 
of  a  bluish  or  greenish  tinge,  and  the  distribution  of  pigment 
around  its  margin,  if  any  be  present,  must  be  noted.  The 
disc  is  often  pinker  than  normal,  shading  off  so  gradually 
into  the  color  of  the  retina  as  scarcely  to  be  distinguished 
from  it  (neuritis).  Or  the  disc  may  be  unduly  pale,  with  a 
deficiency  of  the  minute  vessels  distributed  to  its  substance 
(white  atrophy,  sclerosis).  The  disc  itself  may  be  normal 
or  pale,  even  although  the  large  vessels  in  front  of  it  are  in- 
creased in  number.  The  size  of  the  disc  may  remain  normal, 
although  the  condition  known  as  white  atrophy  is  highly 
marked,  but  the  nerve  may  be  shrunken  as  a  whole  or  in 
particular  parts  (atrophy  with  loss  of  substance,  or  contrac- 
tion).     Traces  of  exudation,  either  in   patches   or  in   the 


142  ORGANS    OP    SPECIAL    SENSE. 

course  of  the  vessels,  are  sometimes  found  associated  with  a 
general  pink  and  prominent  aspect  of  the  disc,  which  assumes 
a  woolly  appearance  ("choked  disc").  The  bloodvessels 
should  also  be  examined  in  their  course,  particularly  as  to 
the  presence  of  hemorrhages :  these  should  be  noted  as  to 
whether  they  seem  true  clots,  or  whether  the  vessels  seem 
to  terminate  in  branching-like  spots  involved  in  patches  of 
white  exudation.  When  reddish  spots  without  any  true 
clot  are  found,  miliary  aneurisms  may  sometimes  be  suspected. 
Large  exudations  forming  irregular  patches,  partly  on  the 
nerve  and  partly  beyond  it,  or  connected  by  streaks  with  the 
disc,  obscuring  the  vessels  and  associated  with  loss  of  vision, 
are  to  be  suspected  as  syphilitic.  Whitish  pearly  spots  of 
exudation  in  the  neighborhood  of  the  macula  lutea  are  com- 
mon in  Bright's  disease  of  the  kidney,  and  larger  patches, 
with  smaller  glittering  spots  elsewhere,  are  also  found  in  this 
aflPection ;  somewhat  similar  patches  are  seen  occasionally  in 
diabetes.  Shining  miliary  tubercles  are  occasionally  seen 
in  the  choroid  in  cases  of  tuberculosis  and  tubercular  menin- 
gitis. 

Significance  of  Ophthalmoscopic  Appearances  in  Medical 

Diagnois Optic   neuritis   and   optic  atrophy  are  the  two 

most  important  conditions  discovered  in  the  fundus  in  the 
examination  of  medical  cases.  Atrophy  is  often  preceded 
by  optic  neuritis  in  cerebral  tumors  and  inflammations,  and 
in  such  cases  the  disc  is  usually  ragged  or  ill-defined  at  cer- 
tain parts ;  in  simple  white  atrophy,  on  the  other  hand,  the 
disc  is  sharply  defined,  but  this  form  of  atrophy  is  less  cha- 
racteristic of  definite  cerebral  affections,  being  found  in  a 
variety  of  conditions.  Great  changes  in  the  fundus  are  ob- 
served from  time  to  time  in  the  progress  of  cerebral  cases 
involving  the  optic  nerve  and  retina  ;  hemorrhages  appear 
and  disappear,  or  give  place  to  patches  of  exudation.  These 
sometimes  become  absorbed,  or  they  may  increase  in  number 
and  size.  The  tendency  is  for  all  these  inflammatory  pro- 
cesses, including  even  cedema  of  the  papilla,  to  terminate  in 
atrophy  of  the  nerve. 

In  attempting  to  explain  the  changes  in  the  fundus  of  the 
eye,  as  bearing  on  medical  diagnosis,  we  must  be  content 
with  comparatively  obscure  indications,  as  the  subject  has 
not  been  sufficiently  long  under  competent  observation  to  lay 
down  general  laws  safely.  The  exudations  described  as 
characteristic  of  syphilis,  or  of  Bright's  disease,  and  miliary 
tubercles,  aneurisms,  or  embolisms  (when  they  can  be  recog- 


EYE — CHOKED    DISC.  143 

nized  as  such)  are  sufficiently  suggestive  of  their  significance. 
In  addition  to  the  exudations  already  described,  hemorrhagic 
spots  are  likewise  found  in  Bright's  disease  (as  well  as  in 
cerebral  cases),  and  the  detection  of  such  always  demands 
an  examination  of  the  urine ;  not  unfrequently  cases  of 
Bright's  disease  come  first  under  notice  from  a  failure  of 
vision  due  to  these  changes.  QEdema  of  the  retina  likewise 
occurs  in  renal  dropsy,  and  its  aggravation  or  subsidence 
may  account  for  the  great  changes  in  the  state  of  the  vision 
which  sometimes  occur  within  short  intervals.  In  endeav- 
oring to  understand  the  ophthalmoscopic  appearances  found 
in  connection  with  cerebral  tumors  and  inflammations,  the 
following  diff^erent  theories  may  be  borne  in  mind,  as  they 
have  been  advanced  to  explain  the  swollen  and  inflamed  state 
of  the  optic  nerve  known  as  the  "  choked  disc."  1.  An  in- 
terruption to  the  return  of  the  blood  from  the  eye,  due  to 
pressure  on  the  cerebral  veins  by  a  tumor,  may  give  rise  to 
congestion  and  slight  fulness  of  the  optic  nerve,  and  there 
may  then  be  induced  a  secondary  increase  of  this  congestion, 
from  strangulation,  as  it  were,  of  the  vessels  of  the  congested 
and  swollen  nerve,  by  its  own  inexpansible  sheath.  2.  Or,, 
the  swelling  congestion,  and  oedema  of  the  disc  may  arise 
from  pressure  in  the  sub-vaginal  space,  either  from  the  pre- 
sence of  exudation  originating  there,  or  from  the  pressure  of 
fluid  forced  along  the  sheath  of  the  optic  nerve  from  the  sub- 
arachnoid space.  3.  An  extension  of  the  inflammatory  pro- 
cess from  the  brain  or  cerebellum,  or  tlie  membranes,  down 
the  course  of  the  optic  nerve,  may  give  rise  to  a  "neuritis 
descendens."  4.  Vascular  changes,  resulting  in  congestion 
of  the  optic  disc,  may  be  due  to  disturbances  of  the  circula- 
tion, brought  about  through  an  indirect  influence  of  the  cere- 
bral tumor,  or  other  mischief,  on  the  vaso-motor  or  sympa- 
thetic system,  apart  from  any  merely  mechanical  eftect,  or 
from  any  continuity  of  inflamed  tissues. 

Optic  neuritis  or  atrophy  due  to  cerebral  causes  is  usually 
double,  although  the  changes  in  one  eye  are  often  more  ad- 
vanced than  in  the  other ;  if  only  one  eye  be  afi^ected,  a 
lesion  on  the  opposite  side  of  the  brain  may  be  presumed. 
Localization  of  the  disease  from  ophthalmoscopic  signs  is 
scarcely  possible,  but  the  comparative  frequency  of  blindness 
and  affections  of  the  optic  nerve  in  tumors  of  the  cerebellum 
is  well  established.  Unilateral  optic  atrophy  (white)  is  not 
unfrequent  in  locomotor  ataxy. 


144  ORGANS    OF    SPECIAL    SENSE. 


THE  EAR. 


The  sense  of  hearing  is  usually  tested  by  means  of  a  watch 
applied  to  or  held  near  the  ear.  We  begin  by  applying  the 
watch  closely  enough  for  it  to  be  distinctly  heard,  and  we 
gradually  remove  it,  in  a  straight  line  from  the  ear,  till  the 
sound  is  lost,  and  by  measuring  this  distance  we  have  a  means 
of  comparison  between  the  two  ears,  and  also  a  rough  gauge 
of  the  absolute  acuteness  of  hearing.  In  other  cases,  low 
speech,  or  notes  of  different  pitch,  at  varying  distances,  or 
loud  sounds,  are  sometimes  tried  to  test  the  power  of  hearing. 
Some  persons  hear  a  watch  badly,  and  conversation  pretty 
well ;  in  others,  again,  this  is  reversed.  A  large  vibrating 
tuning  fork  (C)  applied  to  the  forehead,  to  the  vertex,  or  to 
the  front  teeth  of  the  upper  or  lower  jaw,  likewise  affords 
valuable  assistance,  especially  in  discriminating  deafness  due 
to  nervous  causes  from  that  which  results  from  disorders  of 
the  channels  and  the  mechanism  of  the  ear.  When  the 
sound  of  a  tuning  fork  (or  a  watch)  thus  applied,  is  perceived 
by  the  patient  principally  or  exclusively  on  the  side  on  which 
he  is  deaf,  aurists  conclude  that  the  difficulty  of  hearing  has 
a  peripheral  cause,  and  is  due  to  some  impediment  to  the 
conduction  of  sound :  in  the  opposite  case  a  lesion  of  the 
labyrinth,  or  one  inside  the  cranial  cavity,  may  be  inferred 
with  great  probability.  If  we  close  the  external  meatus  on 
one  side,  and  apply ,a  vibrating  tuning  fork  to  the  vertex, 
and  if  we  find  tiie  sound  much  the  same  on  both  sides,  or 
less  where  the  meatus  is  closed,  there  is  a  probability  of 
some  lesion  of  the  nervous  part  of  the  auditory  organs  on 
that  side. 

When  by  means  of  the  watch  test,  or  otherwise,  we  are 
satisfied  of  an  impaired  state  of  the  hearing,  we  must  examine 
tlie  organs  to  see  if  any  impediment  can  be  found,  such  as  a 
plug  of  wax,  or  any  growth  or  tumor  in  the  meatus,  or  any 
obstruction  in  the  passage  of  the  Eustachian  tubes.  The  ear 
is  illuminated  by  reflecting  light  from  a  concave  mirror 
through  a  speculum  Avhich  straightens  and  slightly  dilates 
the  external  meatus.  Daylight  is  much  the  best,  but  a  lamp 
may  be  required  wlien  this  is  defective.  If  wax  be  found  on 
sucli  an  examination,  the  hearing  should  be  tested  after  its 
removal  by  syringing,  as  it  does  not  follow  that  the  wax  was 
the  sole  or  the  chief  cause  of  the  deafness  complained  of. 
Inquiry  should  likewise  be  made  as  to  the  existence,  at  any 
period,  of  discharges  of  any  kind  from  the  ears  (pus,  blood. 


EXAMINATION    OF    EAR.  145 

or  watery  fluid),  and  in  such  cases  the  likelihood  of  perfora- 
tion, or  even  of  almost  complete  destruction  of  the  membrana 
tjmpani,  must  be  considered.  Fracture  of  the  base  of  tiie 
skull  must  also  be  remembered  in  this  connection.  This  per- 
foration may  demand  a  careful  examination  of  the  ear  by 
means  of  the  speculum,  as  just  described,  but  sometimes  it 
can  be  demonstrated  by  causing  the  patient  to  force  air  into 
his  ear  by  blowing  his  nose  wliile  the  nostrils  are  tiglitly 
compressed  (Valsalva's  method).  In  many  cases  of  perfora- 
tion of  the  membrane,  we  may,  in  this  way,  hear  the  air 
rushing  through  the  meatus.  This  same  experiment  likewise 
enables  us  to  discover  if  the  Eustachian  tube  is  patent;  for 
when  the  tympanum  is  in  its  natural  state  we  may  thus  hear, 
by  means  of  the  aurist's  diagnostic  tube  (or  even  a  stetho- 
scope applied  to  the  external  ear),  a  sliarp  click  from  the 
compression  of  the  air  in  the  cavity  during  the  blowing  of 
the  nose  as  described.  This  method  is  not  available  in  chil- 
dren, or  in  those  adults  who  cannot  be  made  to  do  tlie  ex- 
periment properly.  Pollitzer's  bag,  with  its  tube  introduced 
into  the  nostril,  is  often  useful  in  such  cases,  as  the  air  can 
frequently  be  thus  blown  into  the  Eustachian  tube  daring 
the  act  of  swallowing ;  in  cliildren,  swallowing  is  not  required 
for  the  success  of  this  experiment.  In  other  cases,  again,  the 
proper  investigation  requires  the  air  to  be  actually  blown  into 
the  Eustachian  tube  by  an  instrument  introduced  into  it,  but 
such  manipulations  are  only  to  be  attempted  by  those  specially 
trained  in  aural  surgery.  In  examining  the  Eustachian  tubes 
attention  should  be  directed  to  the  condition  of  the  pharynx, 
tonsils,  and  posterior  nares,  as  many  aural  diseases  begin  in 
this  situation.  A  proper  examination  of  this  region  and  of 
the  orifices  of  the  Eustachian  tubes  may  demand  the  use  of 

Rhinoscopy (See  Chapter  x.)      In  the  examination  by  the 

speculum  and  reflected  light,  we  aim  at  discovering  the  con- 
dition of  the  walls  of  the  meatus,  the  appearance  of  the  mem- 
brana tympani,  whether  it  is  ruptured,  or  whether  distinct 
variations  exist  in  the  curvature  of  the  membrane — such  as 
bulging  towards  the  meatus  or  the  contrary — whether  there  is 
any  abnormality  in  the  reflection  of  the  light  from  the  mem- 
brane, and  whether  there  is  undue  vascularity  in  the  neigh- 
borhood of  the  handle  of  the  malleus  or  elsewhere,  and  even 
an  exploration  of  the  state  of  the  petrous  bone,  in  cases  of 
suppuration,  can  sometimes  be  made,  although  the  probe  is  a 
dangerous  instrument  in  such  situations.  All  these  changes 
point  to  disease  of  the  meatus  and  middle  ear,  and  they  indi- 
13 


146  ORGANS    OP    SPECIAL    SENSE. 

cate  mechanical  causes  for  the  deafness,  and  so  may  remove 
it  from  tlie  realm  of  the  physician.  But  suppuration  in  the 
tympanum,  &c.,  may  throw  a  light  of  the  utmost  value  on 
certain  cerebral  or  pya^mic  symptoms  in  a  case.  Abscess  of 
the  brain  and  meningitis  occasionally  depend  on  some  pre- 
vious suppuration  in  the  ear,  and  this  may  have  extended 
upwards  from  the  throat,  as  in  certain  cases  of  scarlatina. 
Puffiness  over  the  mastoid  process,  with  or  wifehout  present 
or  past  otorrhoea,  is  frequently  found  in  connection  with  sup- 
puration going  on  in  the  mastoid  cells,  and  this  suppuration 
may  be  associated  with  a  train  of  symptoms  indicative  of 
septic  poisoning  or  other  serious  mischief,  to  which  it  may 
supply  the  only  clue.  When  a  degree  of  deafness  exists,  and 
its  cause  cannot  be  referred  to  any  impediment  in  the  pas- 
sages of  the  ear,  we  may  infer  a  lesion  of  the  auditory  nerve 
in  some  part  of  its  course,  and  an  examination  of  the  other 
cranial  nerves  may  throw  some  light  on  the  nature  and  posi- 
tion of  the  lesion  ;  the  presence  of  subjective  symptoms  must 
likewise  be  considered  in  this  connection  (see  p.  158).  The 
occupation  of  the  patient,  and  his  relation  in  this  respect  to 
noises,  the  previous  history  of  blows  on  the  head,  of  attacks 
of  giddiness,  or  of  noises  in  the  ears,  and  the  family  history 
as  to  deafness,  hereditary  syphilis,  &c.,  should  all  be  inquired 
into.  Scarlatina  and  typhus  fever  are  often  complicated 
■with  deafness  during  the  acute  illness,  and  occasionally  as  a 
sequela ;  in  the  former  disease  the  mischief  is  usually  in  the 
mechanism  of  the  ear,  in  the  latter  the  deafness  is  almost 
always  nervous. 

THE  NOSE. 

The  sense  of  smell  is  tested  by  applying  a  phial  charged 
with  very  distinct  odors  to  the  nostril :  one  nostril  should  be 
tested  at  a  time,  the  other  being  compressed,  and  the  mouth 
also  should  be  kept  shut.  If  the  smell  be  not  appreciated  in 
this  way,  the  mouth  may  be  kept  open  while  the  scent  is 
being  sniffed  up,  or  strongly  flavored  materials  may  be  given 
to  be  tasted  or  applied  in  such  a  way  as  to  allow  the  odor  to 
ascend  by  the  posterior  nares.  The  odor  may  be  blown  into 
the  mouth  and  the  person  directed  to  breathe  out  through  his 
nose.  The  patient  may  likewise  be  questioned  regarding  his 
recognition  of  flavors  in  his  food  or  drink,  as  it  has  been 
clearly  ascertained  that  much  of  what  we  discern  by  the 
mouth  is  really  due  to  the  sense  of  smell,  and  that  those  who 


TESTS    FOR    SMELLING.  147 

are  affected  simply  with  a  loss  of  smell  from  nervous  lesion 
(anosmia),  are  incapable  of  discriminating:  the  flavor  of  many 
articles  of  diet  (wines,  coffee,  cheese)  :  such  persons  fre- 
quently teU  us  that  both  smell  and  taste  are  nearly  gone. 

Certain  fallacies  beset  our  investigation  of  this  sense.  1. 
Strongly  pungent  vapors  or  solids  (ammonia,  snuff,  &c.)  may 
be  recognized  by  those  destitute  of  smell,  from  tlie  action  of 
these  irritants  on  the  branches  of  the  fifth  nerve  :  such  things, 
therefore,  must  be  avoided  as  tests  :  assafatida,  musk,  essence 
of  lemon,  &c.,  are  suitable  for  this  purpose.  2.  Smell  may 
seem  lost  from  some  imperfection  in  the  nasal  cavity  apart 
from  any  nervous  lesion :  thickening  of  the  mucous  mem- 
brane from  a  common  cold,  or  more  serious  alterations  in  the 
hard  or  soft  parts,  as  well  as  distinct  growths,  are  frequent 
sources  of  imperfection  in  the  sense  of  smell :  in  such  cases 
smells  may  possibly  still  be  appreciated  (especially  as  flavors) 
by  way  of  the  posterior  nares.  3.  In  facial  paralysis,  proba- 
bly from  some  difficulty  in  directing  the  odorous  current 
properly  to  the  olfactory  tract,  in  sniffing  it  up,  there  is  some- 
times an  imperfect  sense  of  smell  in  the  paralyzed  nostril, 
without  any  real  defect  in  the  first  nerve.  A  dryness  of  the 
nostril  may  likewise  cause  a  defect  in  smell, — tlie  tears  flow- 
ing down  the  cheek  instead  of  into  the  nasal  duct  in  certain 
cases  of  facial  paralysis. 

Loss  of  smell,  as  a  single  lesion,  is  sometimes  met  with  in 
connection  with  injuries  to  the  head  :  but  in  the  case  of  cere- 
bral tumors  and  the  like,  other  nerves  are  usually  involved 
and  not  the  first  nerve  alone. 

"  Running  fz'om  the  nose"  is  one  of  the  symptoms  found 
during  tlie  invasion  of  measles.  Chronic  discharge  from  the 
nose  is  sometimes  simply  catarrhal,  but  it  is  usually  fetid 
(ozoena),  and  often  depends  on  disease  of  the  bones  which 
can  be  detected  by  the  probe.  Such  a  discharge,  in  children, 
from  one  nostril  only,  is  always  suggestive  of  the  presence  of 
a  foreign  body  in  the  nose.  Fetor  from  the  nose  may  be 
distinguished  from  fetor  due  to  gangrene  of  lung,  or  from  that 
of  sore  throat,  disordered  stomach,  carious  teeth,  &c.,  by 
testing  tlie  breath  while  the  mouth  and  the  nostrils  are  closed 
alternately.  The  obstruction  to  the  breathing  through  the 
nose  observed  in  infancy,  and  known  as  "  snuffles,"  is  usually 
due  to  syphilis. 


148  ORGANS    OF    SPECIAL    SENSE. 


THE  SENSE  OF  TASTE. 

The  sense  of  taste  is  not  easily  tested  in  a  satisfactory 
manner.  The  ditficulties  are  the  following.  Some  so-called 
tastes  are  really  appreciated  by  the  olfactory  nerve,  while 
aci'id  substances  may,  perhaps,  be  recognized  by  the  nerves 
of  common  sensation.  Loss  of  taste  from  nervous  causes 
(ageustia)  is  usually  unilateral,  and  when  a  sapid  substance 
is  applied  to  one  side  of  the  tongue  as  a  test,  it  is  apt  to 
pass  over  quickly  to  the  other  side,  or  to  the  soft  palate, 
when  the  tongue  is  taken  in.  To  avoid  this,  the  substance 
may  be  applied  to  the  tongue  while  it  is  kept  protruded,  but 
it  is  found  that  even  in  the  normal  state  it  is  not  easy  to 
recognize  various  tastes  under  such  conditions.  The  sense 
of  taste  proper  seems  to  reside  in  the  tongue  and  soft  palate 
chiefly,  but  the  movements  of  the  tongue  against  the  hard 
palate  and  lips,  and  the  intimate  admixture  of  the  substance 
with  the  secretions  of  the  mouth,  seem  to  be  almost  essential 
for  the  i)roper  appreciation  of  tastes.  A  furtlier  difficulty 
arises  from  the  different  parts  of  the  tongue  having  very  dif- 
ferent degrees,  and  even  kinds,  of  sensation.  The  best  way 
is  to  try  strong  solutions  of  a  sweet  and  of  a  bitter  substance, 
as  these  are  pure  sapids  (sugar  and  picric  acid,  e.  ^.),  and  to 
rub  them  with  the  finger  or  with  a  brush,  very  freely  and 
firmly  on  to  various  parts  of  one  side  of  the  tongue  while  it 
is  protruded,  and  to  ask  the  patient  to  indicate  by  a  movement 
of  the  head  whether,  and  when,  he  recognizes  the  taste  be- 
fore he  takes  in  his  tongue.  If  we  suspect  a  defect  on  one 
side  we  can  sometimes  demonstrate  it  more  clearly  by  apply- 
ing the  test  solution  to  the  affected  side,  and  while  it  is  still 
unrecognized  we  may  touch  the  other  side  of  the  tongue  with 
the  same  substance  before  it  is  taken  in  ;  we  may  thus  find 
that  the  patient  at  once  indicates  his  recognition  of  the  test 
fluid  on  the  sound  side  by  a  sign  or  a  contortion  of  his  face. 
Care  must  be  taken  to  have  tlie  patient's  mouth  thoroughly 
washed  out  before  any  new  substance  is  tried,  as  also  to  have 
the  brushes  or  other  agents  used  in  applying  the  test  tho- 
roughly cleansed,  and  it  is  well  to  begin  with  the  milder 
tastes,  as  the  strong  bitter  substances  linger  a  long  time  in 
the  mouth  and  complicate  further  trials.  In  addition  to 
sweet  and  bitter,  acid  and  salt  substances  may  be  tried,  but 
it  is  not  quite  so  certain  that  these  are  recognized  purely  by 
the  special  sense  of  taste,  as  distinguished  from  that  of  com- 
mon sensation.     Acids  without  smell  must  be  selected  for 


TESTS    FOR    TASTE.  149 

such  trials.  Along  with  tlie  test  bj  sapids,  the  tongue  should 
also  be  tried  as  to  its  tactile  sense  by  the  compasses  (see  pp. 
150,  151);  loss  of  taste  with  perfect  tactile  sensation,  and 
loss  of  tactile  sense  with  perfect  taste,  are  both  occasionally 
found,  as  well  as  loss  of  both  ;  we  must  also,  of  course,  pur- 
sue the  examination  by  testing  the  otlier  cranial  nerves,  &c. 
The  significance  of  a  lesion  of  taste,  when  ascertained,  is 
rendered  somewhat  obscure  by  the  curious  differences  of 
opinion  as  to  the  nerves  of  taste  and  their  real  origin.  The 
glosso-pharyngeal,  for  special  sense  at  the  back  part  of  the 
tongue,  is  generally  recognized  by  all.  The  lingual  branch 
of  the  fifth  nerve  is  admitted  by  all  to  supply  common  sen- 
sation to  the  tongue,  and  most  authorities  consider  it  to  be 
concerned  more  or  less  also  in  the  special  gustatory  sense  : 
the  chorda  tympani  nerve,  however,  wliich  joins  it  from  the 
seventh,  is  regarded  by  many  as  the  nerve  of  special  sense 
for  the  anterior  part  of  the  tongue,  and  it  seems  quite  certain 
that  it  has  something  to  do,  in  some  way,  with  the  sense  of 
taste :  but  admitting  this  as  proved,  it  is  not  quite  certain 
that  the  portio  dura  of  the  seventh  nerve,  in  itself,  really 
contains  sensory  fibres ;  some,  indeed,  allege  that  the  sen- 
sory fibres  in  the  chordo  tympani  come  from  the  "pars  inter- 
media of  the  seventh  pair  or  from  some  junction  with  the  fifth 
nerve  in  ways  which  are  not  always  uniform.  It  is  conceivable, 
moreover,  that  a  nerve  may  affect  the  sense  of  taste  by  an 
indirect  action  on  the  glands  and  papillae,  apart  from  any 
sensory  function.  Wliat  is  certain  is  that  taste  may  be 
affected  in  cases  presenting  evidence  of  a  lesion  in  the  glosso- 
pharyngeal nerve  ;  that  it  may  be  affected,  or  preserved,  in 
cases  presenting  definite  lesions  of  the  fifth  nerve,  including 
among  these  aniesthesia  of  the  tongue ;  and  that  it  is  some- 
times affected  in  cases  presenting  the  well-known  features  of 
paralysis  of  the  portio  dura  of  the  seventh  pair,  arising  from 
disease  of  the  ear  and  other  peripheral  causes.  The  varia- 
tion as  to  the  presence  of  the  affection  of  taste  in  this  facial 
paralysis  depends  probably  on  the  exact  locality  at  which  the 
lesion  of  the  seventh  nerve  exists ;  when  this  paralysis  is 
due  to  a  cerebral  lesion,  the  taste  does  not  appear  to  be 
affected. 

The  taste  may  also  be  affected  in  various  ways  in  general 
diseases,  such  as  insanity  and  hysteria  ;  and  from  more  local 
causes  affecting  the  tongue,  such  as  dryness  in  febrile  disease, 
foul  coating  in  dvspepsia,  stomatitis,  and  the  like. 

13* 


150  ORGANS    OP    SPECIAL    SENSE. 


COMMON  SENSATION. 

llie  tactile  sense  is  very  unequally  distributed  over  the 
cutaneous  and  mucous  surfaces,  some  parts  being  very  much 
more  sensitive  than  otliers.  Defects  in  the  acuteness  of  this 
sense  are  often  conn)lained  of  in  particular  parts,  and  so  it 
becomes  important  not  only  to  verify  the  existence  of  this 
anjesthesia,  but  also  to  define  with  some  accuracy  its  degree 
and  its  distribution.  Various  methods  are  pursued.  The 
patient  may  be  touched  lightly  with  the  finger  in  various 
parts,  the  observation  being  of  course  varied  with  blank 
experiments,  and  he  should  be  asked,  while  his  eyes  are  shut, 
whether  and  at  what  part  he  is  touched.  It  is  found  that  in 
anaesthesia  the  precision  of  localizing  the  sense  of  impact  is 
much  diminished.  If  the  defect  be  very  slight  the  patient 
may  be  tried  with  the  most  delicate  impressions  possible,  such 
as  result  from  the  touching  of  a  hair ;  if,  on  the  other  hand, 
the  sense  be  very  dull,  the  point  of  a  pin,  or  the  pinching  of 
the  skin,  may  be  used  to  produce  a  distinct  impression,  and 
by  the  patient's  answers,  or  the  expression  of  his  face,  we 
may  be  able  to  define  the  area  of  impaired  sensation.  In 
conducting  such  experiments  it  should  be  noticed  if  the  per- 
ception of  the  impact  is  distinctly  delayed,  as  this  indicates 
a  bluntness  in  the  sense.  Other  methods  of  testing  the  sen- 
sation consist  in  trying  if  the  patient  can  recognize  by  the 
hand,  and  with  his  eyes  shut,  different  textures  of  cloth, 
flannel  from  cotton  for  example,  or  if  he  can  say  whether  a 
carpet,  or  a  rough  or  a  smooth  substance,  is  interposed  be- 
tween his  bare  foot  and  the  floor,  care  being  taken  that  there 
is  no  great  difference  in '  the  temperature  of  these  objects. 
The  lifting  of  minute  objects  by  the  hand,  the  discrimination 
of  coins — such  as  a  threepenny-piece  i'rom  a  Iburpenny- 
piece,^ — and  the  manipulation  of  worsted  or  cotton  yarn  in 
sewing  or  knitting,  often  enable  us  to  judge  of  the  degi'ee  of 
tactile  sense  remaining  with  considerable  certainty  ;  blind- 
folding the  patients  often  brings  out  very  prominently  the 
loss  of  tactile  sense,  as  we  may  find  them  groping  about  with 
their  hands  for  objects  which  are  already  actually  touching 
their  fingers.  These  methods,  or  at  least  some  of  them,  are 
applicable  to  various  ages  and  various  grades  of  intelligence, 
but  a  greater  precision  is  sometimes  obtainable  by  means  of 
the  compasses  (Weber's  test).     Considerable  intelligence  is 

'  From  the  pi*esence  of  a  milled  edge. 


TACTILE    SENSE.  151 

required  to  secure  reliable  results  by  this  process,  and  the 
patients  often  seem  so  stupid  or  careless,  or  fatigued,  as  to 
render  the  results  a  mass  of  confusion.  The  essence  of  the 
test  consists  in  discovering  the  smallest  distance  at  which 
the  two  points  of  a  pair  of  compasses,  simultaneously  and 
lightly  applied  to  the  surface,  can  be  recognized  by  the  touch 
as  two  separate  objects.  The  points  should  be  blunted  in 
some  way  (except,  perhaps,  in  the  case  of  the  finger  tips  and 
other  sensitive  parts)  ;  cork  or  sealing  wax  serves  this  pur- 
pose, or  the  points  themselves  may  be  rubbed  down.  The 
patient  should  first  be  informed,  with  his  eyes  open,  as  to 
the  process  of  testing  to  be  attempted,  a  few  trials  being 
made  to  let  him  know  the  object  aimed  at.  The  eyes  should 
then  be  shut,  or  the  vision  obstructed  in  some  way,  and  the 
compass,  widely  opened,  applied  so  as  to  give  a  distinct  im- 
pression of  two  separate  points  ;  the  points  should  then  be 
gradually  approximated  till  they  are  felt  as  if  they  made 
only  one  impact,  or  till  the  answers  become  confused  and 
unreliable,  in  which  case  we  may  revert  after  a  time  to  the 
same  part  to  see  if  the  same  result  is  obtained.  During  this 
gradual  approximation  of  the  points  of  the  compasses,  an 
occasional  variation  by  the  im)jact  of  only  one  limb  of  the 
compasses,  should  be  introduced  so  as  to  make  sure  that  the 
patient  is  not  answering  at  random. 

The  following  directions  should  be  attended  to  :  1.  The 
two  points  must  be  put  down  simultaneously,  otherwise  the 
succession  of  the  impacts  leads  of  itself  to  the  inference  of 
two  points.  2.  The  part  of  the  patient  under  observation 
should  be  kept  quite  unmoved  and  steady  ;  patients  instinc- 
tively, while  in  doubt,  tend  to  move  the  fingers  or  hand  to 
satisfy  themselves  whether  two  points  are  applied,  as  they 
get  in  this  way  also  a  succession  of  impressions.  3.  The 
two  points  should  be  always  kept  in  the  same  relative  direc- 
tion in  making  estimates  of  the  delicacy  of  sensation  in  the 
same  limb,  i.  e.,  we  must  keep  always  either  in  the  axis  of 
the  limb  or  always  transversely  to  it. 

The  following  list  may  serve  as  an  indication  of  the  normal 
sensitiveness  of  different  parts,  but  it  cannot  be  regarded  as 
absolute ;  a  comparison  of  the  sensation  on  the  two  sides  of 
the  body  indicates  changes  in  a  more  reliable  manner  when 
the  lesion  is  unilateral.     (Selected  from  Weber's  table.) 


152 


ORGANS    OF    SPECIAL    SENSE. 


Point  of  the  tongue 

V 

ine 

Red  surface  of  lips 

2 

Dorsum    and     edge    of 

Lips  where  covered  with 

tongue 

41 

ines 

skin  .         .         .         . 

4 

Palmar   surface    of    3d 

Dorsal    surface    of    3d 

phalanx     . 

1 

" 

phalanx     . 

3 

Palmar   surface    of    2d 

Dorsal    surface    of    1st 

phalanx     . 

2 

li 

phalanx     . 

7 

Palmar  surface  of  meta- 

Dorsum    of    hand     at 

carpus 

3 

a 

knuckles   .         .         . 

8 

Skin  of  cheek 

3 

(t 

Middle  of  thigh     . 

30 

Tip  of  the  nose 

3 

li 

Over  patella 

16 

Lower  part  of  forehead  . 

10 

i  i 

Dorsum  of  foot  near  toes 

18 

Neck  under  jaw    . 

15 

a 

Penis     .         .         .         . 

18 

Skin  beneath  occiput     . 

24 

a 

Upper  dorsal  vertebrse  . 

24 

Sternum 

20 

a 

Middle  dorsal  vertebrse . 

30 

2  lines 


The  area  of  diminished  sensation,  or  of  complete  anaes- 
thesia, often  enables  us  to  refer  the  defect  to  a  single  nerve, 
or  to  a  special  branch  of  a  nerve.  The  extent  of  the  area  of 
anaesthesia,  and  its  level  in  the  trunk,  may  enable  us  to  de- 
fine the  locality  of  the  lesion  in  the  spinal  cord  to  which  it  is 
due.  Anaesthesia  is,  indeed,  very  often  due  to  spinal  lesions, 
but  is  sometimes  found  in  more  general  diseases,  after  diph- 
theria for  example,  in  hysteria,  and  occasionally  in  other 
affections  clearly  of  a  functional  character.  (See  Electrical 
Tests  for  Anaesthesia,  Chapter  vii.)  In  cases  of  ovarian 
irritation  certain  limited  areas  of  auDssthesia  can  sometimes 
be  made  out;  occasionally  the  antesthesia  in  such  cases  only 
extends  to  one  side  of  the  body  (hemi-anaesthesia)  ;  such  uni- 
lateral anaisthesia  is  found  also  in  some  cases  of  cerebral  dis- 
ease (posterior  part  of  internal  capsule),  associated  with 
paralysis  of  the  same  parts.  In  locomotor  ataxy  anaesthesia 
of  the  feet  and  legs  is  very  common.  (Compare  section  on 
Paralysis  with  Anaesthesia,  p.  168.)  Anaesthesia  is  frequently 
caused  by  pressure  on  the  nerves,  as  by  tight  bandages, 
splints,  crutches,  &c.,  or  by  more  serious  forms  of  pressure 
arising  from  malignant  tumors,  aneurisms,  abscesses,  &c. 

The  trophic  effects  of  nervous  lesions  must  be  noted,  when 
present,  as  important  facts  in  cases  of  anaesthesia ;  ulcera- 
tions of  the  cornea  in  the  case  of  the  fifth,  glazing  of  the  skin, 
grayness  of  the  hair,  and  the  like,  are  to  be  named  in  this 
connection.  Anaesthesia  can  occasionally  be  shown  to  exist 
in  an  area  affected  with  neuralgia,  and  a  certain  degree  of 
anaesthesiti — a  dulled  perception  of  tactile  impressions — is 
habitually  present  in  cases  of  so-called  hypera^sthesia  in  which 
slight   irritations  of  the  skin    produce  painful  impressions. 


SUBJECTIVE    DISORDERS    OF    SPECIAL    SENSES.       153 

Dulness  as  regards  tactile  impressions  is  to  be  distingui-shed 
from  dulness  to  painful  sensations.     (Analgesia.) 

Diminished  sensitiveness  of  the  fauces,  epiglottis,  &c., 
sometimes  determines  the  occurrence  of  choking  or  of  pul- 
monary aifections,  especially  in  the  insane. 

The  sense  of  temperature  is  probably  a  form  of  common 
sensation,  but  it  is  found  to  be  preserved  in  certain  cases  in 
which  the  tactile  sense  is  diminished  (locomotor  ataxy,  e.  g.). 
It  may  be  tested  by  applying  sponges  dipped  in  water  of 
varying  temperatures,  and  ascertaining  if  the  patient  can  ap- 
preciate the  changes  from  one  temperature  to  another.  A  hot 
sponge  applied  to  the  back  is  sometimes  felt  to  be  acutely 
painiul,  but  this  is  I'ather  a  form  of  spinal  tenderness  than  of 
change  in  the  cutaneous  sensibility. 

THE  MUSCULAR  SENSE. 

The  "  muscular  sense"  is  a  name  applied  by  some  to  the 
faculty  we  possess  of  judging  of  weight.  This  faculty  is 
often  very  defective  in  locomotor  ataxy,  and  has  been  sup- 
posed to  account  for  the  incoordination  of  the  movements 
Ibund  in  this  disease.  In  the  case  of  the  upper  limbs  vari- 
ous weights,  of  as  nearly  as  possible  the  same  bulk,  may  be 
given  as  tests  while  the  patient's  eyes  are  closed,  and  it  can 
then  be  seen  how  far  he  is  able  to  discriminate  them  by  his 
muscular  sense.  For  light  objects  coins  answer  admirably 
— half  a  sovereign  and  a  sixpence,  for  example.  In  testing 
the  lower  limbs  the  patient  may  be  placed  on  a  high  seat, 
with  his  feet  quite  off  the  ground,  or  one  leg  may  be  swung 
over  the  other,  and  various  weights,  enclosed  in  a  bag  or  at- 
tached by  any  other  convenient  arrangement,  may  be  sus- 
pended on  the  foot,  and  the  power  he  has  of  estimating 
weights  may  thus  be  gauged. 

SUBJECTIVE  DISORDERS  OF  SPECIAL  SENSES. 

In  the  preceding  sections  derangements  in  the  organs  ot 
sense  have  been  considered  from  the  objective  point  of  view 
■ — ^.  e.,  the  discovery  of  an  obvious  change,  or  at  least  the 
clear  demonstration,  by  a  reliable  test,  of  some  actual  dis- 
ease. Our  attention,  indeed,  is  usually  directed  to  some  of 
these  by  the  complaints  of  the  patients  themselves,  but  many 
abnormal  sensations  are  spoken  of  by  them  which  we  must 
accept  for  what  they  are  worth,  simply  and  absolutely  on 
their  own  statements. 


154       SUBJECTIVE    DISORDERS    OF    SPECIAL    SENSES. 


DISORDERS  OF  VISION 

are  often  complained  of  in  this  way.  Polyopia  Monocu- 
laris,  or  manifold  vision  with  a  single  eye,  is  comparativel}'" 
rare,  and  is  always  due  to  some  error  in  the  eyeball  itself. 
Irregularities  of  the  crystalline  lens  or  cornea,  and  the  pres- 
ence of  artificial  pupils,  are  the  recognized  causes  of  this 
affection,  so  that  it  has  no  significance  in  medical  diagnosis. 

Diplopia  (double  vision  when  both  eyes  are  open)  is  due 
to  paralysis  or  to  a  want  of  proper  balance  in  the  muscular 
adjustments  of  the  eye.  This  kind  of  diplopia  is  associated 
with  a  tendency  to  squinting,  even  although  no  actual  squint 
may  be  detected  ;  indeed,  when  squinting  is  fully  established, 
diplopia  usually  ceases.  Diplopia  is  sometimes  complained 
of  by  adults  at  the  beginning  of  meningitis  (probably  from 
a  slight  paralysis),  but  is  likewise  produced  in  some  persons 
by  less  serious  disturbances  ;  derangement  of  the  digestive 
organs,  for  example,  may  bring  it  on.  In  certain  cases  of 
drunkenness  there  is  a  want  of  co-ordination  of  the  ocular 
muscles,  producing  double  vision ;  a  similar  condition  is 
found  in  the  early  stages  of  locomotor  ataxy,  without  any 
pei'raanent  squint,  as  well  as  in  the  later  stages,  when  a  true 
paralysis  of  the  ocular  muscles  may  supervene.  Even  when 
due  to  disturbance  of  the  cerebral  functions,  diplopia,  like 
strabismus,  is  particularly  apt  to  occur  in  those  whose  eyes 
are  not  normal  as  regards  refi"action.  For  details,  and  also 
regarding  ohliquity  in  the  objects  looked  at — see  pp.  129  and 
133. 

An  erroneous  estimate  of  the  position  of  objects  is  com- 
mon in  cases  of  paralysis  of  the  ocular  muscles,  so  that  a 
person  whose  right  external  rectus  is  aflfected,  when  asked 
to  strike  an  object  placed  on  his  right,  is  often  found  to 
make  a  mistake ;  this  probably  arises  from  the  mind  being 
conscious  of  an  unduly  great  energy  being  directed  to  the 
pai'alyzed  muscle ;  it  appears  probable  that  the  position  of 
objects  is  estimated  from  this  "outgoing  current,"  as  it  is 
termed.  This  erroneous  estimate  of  the  position  of  objects 
in  certain  directions  leads  to  constant  confusion  from  the 
changes  which  occur  in  the  position  of  objects  as  the  person 
walks  along  or  even  moves  his  eyes  ;  hence  arises  the  "  mo- 
nocular vertigo"  which  occurs  in  cases  of  paralysis  of  the 
third  nerve,  for  example,  if  the  sound  eye  be  closed  and  the 
drooping  lid  held  up  as  the  patient  walks  along.  A  some- 
what analogous  confusion  and  vertigo  may  result  from   bi- 


ASTHENOPIA.  155 

nocular  diplopia,  or  from  conditions  bordering^  on  this  state. 
An  erroneous  estimate  of  the  position  of  objects,  or  of  the 
position  of  the  false  image  in  diplopia,  from  an  apparent  for- 
ward displacement,  is  found  to  occur  in  certain  cases  of  ocu- 
lar paralysis,  particularly  when  the  fourth  nerve,  and  the 
superior  oblique  muscle  are  involved. 

The  accommodation  of  the  eyes  for  distinct  vision  of  near 
objects  becomes  defective  with  age  (about  fifty  years  of  age) ; 
this  "presbyopia,"  as  it  is  called,  is  probably  due,  in  part  at 
least,  to  changes  in  the  lens  itself;  such  defects  become  more 
pronounced  and  occur  at  an  earlier  age  in  those  who  are 
hypermetropic,  and  so  require  to  use  their  accommodation 
even  for  distant  vision.  The  accommodation  may  be  defec- 
tive from  some  nervous  lesions,  as  when  the  third  nerve  is 
paralyzed,  and  diphtheritic  paralysis  of  the  accommodation 
is  not  uncommon.  The  size  of  the  pupil  is  not  always 
affected  when  the  accommodation  is  paralyzed,  although 
both  are  very  often  involved  together.  When  the  vision  is 
defective  Irom  this  cause  convex  glasses  (-}-  12)  should  cor- 
rect it  fully.  (Atropine,  it  must  be  remembered,  paralyzes 
the  accommodation  pro  tempore.^ 

Strain  on  the  eyes,  a  sense  of  fatigue  readily  induced,  and 
a  great  tendency  to  confusion  of  the  lines  and  words  in  a 
book,  after  reading  for  a  few  minutes,  constitute  the  indica- 
tions of  "  asthenopia."  This  strain  may  be  prolonged  or 
intensified  to  such  an  extent  as  to  give  rise  to  headache  of 
such  a  character  as  to  suggest  cerebral  mischief.  This  ex- 
cessive strain  may  be  due  to  some  specially  exacting  form  of 
work  arising  in  connection  with  the  constant  and  extreme 
demands  made  on  the  power  of  the  accommodation  or  of  the 
convergence ;  sometimes,  indeed,  the  combination  of  dif- 
ferent and  unnatural  degrees  of  accommodation  and  con- 
vergence may  produce  this  strain,  particularly  in  those  who 
use  glasses.  These  excessive  demands  arise  in  connection 
with  optical  defects  of  the  eye — hypermetropia,  myopia,  and 
astigmatism — in  the  last  the  varying  demands  are  incessant 
and  most  exacting.  The  headaches  arising  from  the  strain 
thus  produced,  although  at  first  induced  directly  by  taxing 
the  eyes,  may  continue  in  a  more  permanent  form,  so  as  to 
give  little  or  no  suggestion  of  an  ocular  origin  of  the  disorder. 
Some  of  the  defects  cause  a  constant  strain  on  the  eyes,  which 
cannot  be  relieved  by  any  amount  of  apparent  rest. 

Muscce  or  motes  are  to  be  distinguished  according  as  they 
are  fixed  or  floating.     Musca^  volitantes — motes  flying  about 


156      SUBJECTIVE    DISORDERS    OP    SPECIAL    SENSES. 

in  the  field  of  vision — may  be  seen  by  any  liealthy  eye,  and 
in  such  cases  tliey  are  due  to  minute  opacities  normally 
existing  in  the  vitreous.  They  may  be  demonstrated  by  look- 
ing at  a  light  through  a  minute  hole  in  a  blackened  card  ;  in 
this  way  the  eye  is  thrown  out  of  focus,  and  the  shadows  are 
projected  on  tlie  retina.  Motes  like  the  strings  thus  seen, 
and  also  motes  darting  in  various  directions,  may  be  seen  at 
times  a[)art  from  disease,  especially  on  looking  at  dazzling 
white  objects ;  they  are  often  rendered  more  obtrusive  in 
myopic  eyes,  and  in  conditions  of  weakness  and  irritability 
of  the  retina  from  whatever  cause.  Motes  from  these  normal 
opacities  must  be  distinguished  from  floating  specks  due  to 
abnormal  opacities  in  the  vitreous ;  the  latter  are  generally 
visible  with  the  ophthalmoscope.  Fixed  muscse — fixed  black 
spots  or  bands — are  due  to  opacities  in  the  substance  of  the 
retina.  Opacities  in  the  lens  are  revealed  by  ophthalmo- 
scopic illumination  as  black  bands  or  streaks,  but  they  are 
not  perceived  by  the  patient  as  such,  unless  the  eye  be 
thrown  out  of  focus  as  by  the  experiment  with  the  blackened 
card,  just  described,  or  in  some  similar  manner. 

Hemiopia When    the   patient   complains   that    he  sees 

only  one-half  of  an  object,  this  is  due  to  a  defect  in  one 
(lateral)  half  of  the  field  of  vision,  %.  e.,  to  defect  of  the 
retina  on  the  half  opposite  the  unseen  or  blank  part.  It  is 
always  an  affection  of  the  optic  nerve,  and  its  accurate  limi- 
tation to  one-half  of  the  field  of  vision  is,  no  doubt,  related 
in  some  way  to  the  decussation  of  the  fibres  of  the  optic 
nerve  at  the  commissure,  or  the  division  of  its  root  at  the 
thalamus,  but  the  exact  nature  of  this  affection  remains  still 
uncertain.  Hemiopia  is  met  with  occasionally  in  cerebral 
tumors  and  similar  lesions ;  it  usually  affects  both  eyes  ;  the 
commonest  combination  is  to  have  the  nasal  side  of  one  eye 
and  the  temporal  of  the  other  affected.  Hemiopia  is  some- 
times combined  with  hemi-anajsthesia,  the  person  is  blind 
on  the  side  with  which  he  would  otherwise  look  on  his 
affected  limbs.  If  the  two  inner  sides  be  involved,  the  hemi- 
opia is,  of  course,  less  marked  :  it  is  seldom  that  an  upper  or 
an  under  half  is  involved.  One  eye  is  sometimes  affected 
alone. 

Flashes  of  light  (photopsia)  are  produced  by  irritation  ot 
the  retina,  or  of  the  optic  nerve  in  any  part  of  its  course 
from  the  brain.  Even  gentle  pressure  on  the  eyeball  gives 
rise  to  circles  or  flashes  of  light,  and  blows  produce  more 
violent  flashes   in  the   same  way ;  such   sensations  are  fre- 


■OHROMOPSIA AMBLYOPIA.  ISiT 

quent  in  incipient  disease  of  the  optic  nerve.  Flashes  of 
light  are  likewise  often  complained  of  by  those  whose  cere- 
rebral  arteries  ai-e  rigid,  and  in  wliom  disturbances  of  the 
circulation  in  the  optic  nerve,  or  in  the  cerebral  centres  con- 
nected with  it,  may  be  presumed  to  exist ;  they  are  recog- 
nized as  amongst  the  prodromata  of  apoplectic  and  other 
cerebral  seizures. 

Colored  spectra  (chromopsia)  are  of  soniewdnat  similar 
nature ;  they  have  been  known  to  usher  in  epileptic  fits. 
Yellow  vision  (xanthopsia)  is  observed  in  certain  cases  of 
jaundice,  but  it  is  rare,  at  least  in  a  highly  marked  form  ;  it 
is  occasionally  produced  by  santonine  administered  inter- 
nally ;  this  predominance  of  yellow  renders  the  recognition 
of  red  difficult. 

Color -hlindn ess  is  not  uncommon  as  a  congenital  or  even 
as  an  hereditary  defect.  Red  and  its  compounds  are  the 
colors  most  commonly  affected.  No  special  significance  can 
be  at  present  attached  to  this  congenital  defect.  A  degree 
of  color-blindness,  however,  is  often  found  in  connection 
with  blind  spots  in  tlie  central  part  of  the  retina,  and  in 
this  way  it  has  a  place  as  one  of  the  symptoms  of  optic 
atrophy.  In  testing  for  color-blindness,  samples  of  colored 
paper  or  wool  may  be  given  to  the  patient  to  be  compared 
or  matched. 

Hemeralopia^  called  also  "  night  blindness,"  consists  in 
the  inability  to  see  properly  towards  evening,  as  the  daylight 
declines.  It  is  found  in  soldiers  and  others  who  have  been 
exposed  to  dazzling  lights.  It  has  no  special  significance  to 
the  physician.  This  symptom  is  found  also  in  the  affection 
known  as  retinitis  pigmentosa. 

Photophobia,  or  intolerance  of  light,  is  common  to  many 
diseases  of  the  eye  (keratitis,  iritis,  and  retinitis).  It  is  also 
found  in  certain  stages  of  meningitis,  cerebral  tumors,  typhus, 
measles,  &c.  In  nervous  subjects  it  may  exist  apart  from 
any  serious  changes  in  the  eyeball,  constituting  a  hyperees- 
tliesia  of  the  retina. 

Dimness  of  vision  (^amblyopia')  and  blijidness  are  due  to 
many  causes,  coming  for  the  most  part  within  the  realm  of 
the  oculist  alone,  and  these  need  not  be  referred  to  here,  but 
when  associated  with  evidence  of  cerebral  or  renal  affections, 
dimness  of  vision  has,  of  course,  special  interest  to  the  phy- 
sician. It  is  also  one  of  the  symptoms  of  a  general  weak- 
ness— the  muscular  weakness  affecting  either  the  accommo- 
dation or  the  convergence  of  the  eyes.  Anajmia,  in  like 
14 


158       SUBJECTIVE    DISORDERS    OF    SPECIAL    SENSES. 

manner,  may  affect  the  retina ;  thus  loss  of  blood,  flooding, 
prolonged  discharges,  as  in  leucorrhoea  and  protracted  suck- 
ling, or  even  a  sudden  assumption  of  the  erect  posture  in 
cases  of  debility,  may  bring  on  more  or  less  dimness  of  vision ; 
this  is  not  uncommon  just  before  death. 
Spectral  illusions.     (See  Chapter  viii.) 

PERVERSIONS  OF  SMELL  AND  TASTE. 

Perversions  of  smell  and  taste  as  distinguished  from 
mere  loss  of  these  senses  (see  p.  147),  are  almost  entirely 
limited  to  cases  of  insanity  or  other  serious  affections  of  the 
brain  and  nervous  centres  (including  hysteria).  Such  per- 
versions are  intimately  associated  with  the  delusions  from 
which  the  insane  suffer,  and  may  even  give  rise  to  some  of 
these,  especially  when  they  suppose  that  their  food  is  poi- 
soned, that  they  themselves  are  foul  and  fetid,  &c.  Bad 
smells  and  tastes  are  often  experienced  by  patients  in  reality, 
although  it  may  be  difficult  or  impossible  at  the  moment  for 
another  person  to  verify  their  existence,  as  in  slight  cases  of 
ozoena,  or  of  gangrene  of  the  lung,  or  in  cases  of  dyspepsia 
Avith  eructations  of  sulphuretted  hydrogen  or  other  nauseous 
gases.  The  use  of  certain  medicines,  phosphorus,  and  some 
metallic  salts,  likewise  gives  rise  to  curious  smells  and  tastes. 
The  use  of  bismuth  sometimes  gives  rise  to  a  smell  resem- 
bling garlic. 

NOISES  IN  EAR. 

Noises  in  the  ear  (Tinnitus  aurium)  are  often  complained 
of,  sometimes  associated  with  past  or  present  deafness,  some- 
times without  any  defect  in  hearing.  The  noises  vary  in 
degree  from  very  slight  sounds,  only  heard  when  everything 
around  is  perfectly  still,  up  to  noises  so  distressing  as  scarcely 
to  be  bearable.  They  are  often  ti'aceable  to  some  mechani- 
cal cause,  giving  rise  to  pressure  on  the  labyrinth,  either  di- 
rectly or  indirectly.  Thus  wax  pressing  on  the  membrana 
tympani,  or  obstructions  in  the  Eustachian  tube  altering  the 
pressure  of  the  air  in  the  tympanum,  can  sometimes  be  shown 
(by  the  effect  of  their  removal)  to  have  been  the  cause  of 
tinnitus.  It  should  be  remembered,  however,  that  appa- 
rently similar  obstructions  may  exist  without  producing  this 
symptom.  Perforation  of  the  membrana  tympani,  when 
caused  by  violent  noises,  &c.,  is  almost  always  associated 
with  tinnitus  for  a  time,  although  not  itself  a  cause  of  this 


TINNITUS    AURIUM.  159 

symptom  ;  in  cases  of  deafness,  also,  brought  on  by  blow?i  on 
the  head,  tinnitus  is  often  present.  In  certain  cases  the 
noises  in  the  ear  seem  to  be  due  to  actual  mischief  in  the 
labyrinth  itself,  and  especially  to  pressure  of  the  stapes  on 
the  foramen  ovale;  such  pressure  may  arise  from  disease  of 
the  external,  middle,  or  internal  ear.  A  lesion  of  the  laby- 
rinth is  especially  probable  in  those  cases  where  the  noises 
are  associated  with  some  degree  of  deafness,  and  with  sudden 
and  violent  attacks  of  giddiness,  and  a  tendency  for  the  pa- 
tient to  turn  or  to  fall  to  one  side  (Meniere's  disease).  Oc- 
casionally the  noises  in  the  ear  appear  (like  certain  forms  of 
deafness)  to  be  purely  nervous,  coming  and  going  irregularly, 
or  especially  produced  or  aggi'avated  in  connection  with 
mental  annoyance  and  over-fatigue ;  or  developed,  like  cer- 
tain forms  of  weak  sight,  by  prolonged  lactation,  &c.  Noises 
in  the  ear  have,  in  certain  cases,  their  explanation  in  dis- 
turbances existing  in  the  brain  itself,  or  in  its  circulation; 
like  flashes  of  light,  they  form  part  of  the  prodromata  of 
apoplectic  attacks.  In  certain  cases  of  acute  diseases  (ty- 
phus), and  in  some  nervous  complaints,  the  hearing  is  abnor- 
mally acute,  so  that  very  slight  sounds,  otherwise  likely  to 
escape  notice,  seem  to  be  painfully  loud,  although  in  other 
stages  of  typhus  and  enteric  fever  deafness  is  often  present. 
Quinine  in  full  doses  often  produces  more  or  less  noise  or 
ringing  in  the  ears ;  great  differences  exist  as  to  the  suscepti- 
bility of  patients  in  respect  of  quinine.  Salicine  and  sali- 
cylic acid  may  also  give  rise  to  the  same  symptom.  Sometimes 
the  noise  or  singing  in  the  ears  is  due,  in  all  probability,  to 
the  patients  actually  hearing  sounds  produced  in  their  own 
veins;  possibly  they  sometimes  hear  sounds  produced  by  the 
circulation  of  the  blood  in  the  rigid  arteries  at  the  base  of 
the  brain  in  cases  of  atheroma. 

A  whiffing  sound,  as  if  close  at  the  ear,  corresponding 
with  the  arterial  pulsations,  is  often  complained  of  by  persons 
affected  with  some  disorder  of  the  heart's  action  (usually  of 
a  functional  character),  and  associated  Avith  a  sense  of  throb- 
bing throughout  the  artei'ies;  this  sound  distresses  them 
chiefly  while  lying  on  the  left  side,  and  indeed  often  renders 
this  posture  in  bed  impossible. 


160  TESTING    OP    CRANIAL    NERVES. 

DIMINUTION  AND  PERVEESION  OF  THE  CUTANEOUS 
SENSIBILITY. 

Ancesthesia  is  described  by  patients  as  a  "numbness"  or 
"  deadness"  of  the  affected  parts,  or  occasionally  as  if  thick- 
ened skin,  leather.  India-rubber,  or  even  air  cushions  were 
interposed  between  their  feet,  or  other  affected  parts,  and  the 
objects  touched.  These  sensations  may  be  regarded  as  due 
to  pure  defects.  Associated  Trith  anaesthesia,  there  may  be 
in  the  same  part  "  hyjjercEsthesia,"  that  is  to  say,  painful 
sensations  fi'om  irritations  -which  in  the  normal  state  would 
scarcely  be  noticed:  thus  a  light  touch  affecting,  perhaps, 
only  the  hairs  of  the  skin,  or  a  slight  current  of  air,  may  be 
felt  by  such  patients  as  acutely  painful:  but  as  there  is  in 
hyperaesthesia  no  real  increase  of  delicacy  in  touch,  but 
almost  always  a  diminution,  the  term  "  partesthesia"  would 
better  express  this  perverted  sensation.  The  feeling  of 
'■'^pins  and  needles"  in  a  limb  {Scottice  '■'■  j)rinMing")  is  often 
complained  of  in  paralysis  :  the  feeling  is  somewhat  similar 
to  that  experienced  by  every  one  at  times  when  by  accident 
undue  pressure  is  made  on  certain  yjarts  of  a  limb,  as  on  the 
arm  by  lying  on  it,  &c.  Allied  to  this  tingling  is  the  feeling 
as  if  small  insects  were  crawling  over  the  body  {^'■formica- 
tion"^ ;  other  creeping  feelings,  and  sensations  as  if  the  hairs 
of  the  body  were  standing  on  end  {horrijiihition,  goose-flesh), 
are  complained  of  in  various  nervous  affections,  and  also  in 
febrile  disturbances.  Feelings  of  jiushing,  both  local  and 
general,  and  of  coldness,  or  of  cold  water  trickling  down  a 
part,  are  often  experienced  in  nervous  affections,  especially 
hysteria  and  hypochondriasis,  as  well  as  in  certain  febrile 
states  (see  Pyrexia,  p.  87).  Coldness  of  the  limbs  is  often 
bitterly  complained  of  in  paralysis,  although  the  parts  may 
seem  only  slightly  colder  than  natural.  A  feeling  of  con- 
sfricfioyi  of  the  trunk,  as  if  the  clothes  were  too  tightly  fas- 
tened around  the  body,  or  as  if  a  card  were  tightly  compress- 
ing it,  is  often  present  in  spinal  affections.  Some  of  the  above 
perverted  sensations  pass  into,  or  are  associated  with  actual 
pain  in  various  parts. 

TESTING  OF  THE  CRANIAL  NERVES. 

In  many  cases  of  paralysis  the  critical  examination  of  the 
cranial  nerves  may  enable  us  not  only  to  pronounce  on  the 
cerebral  nature  of  the  illness,  but  even  to  localize  the  lesion 


CRANIAL    NERVES  —  FIRST    AND    FIFTH.  161 

in  some  part  of  the  brain.  In  certain  cerebral  affections, 
moreover,  it  occasionally  happens  that  only  one  or  two  nerves 
are  paralyzed,  and  these  may  escape  attention  unless  we  test 
the  nerves  systematically  :  variations  in  the  paralysis  like- 
wise occur  from  time  to  time,  in  certain  cases  of  cerebral 
tumor,  and  even  a  more  transient  paralysis  of  these  nerves  is 
sometimes  seen  in  cerebral  abscess. 

First  Nerve Olfactory — supplies   the   sense  of  smell. 

(See  pp.  146  and  158.) 

Second  Nerve. — Optic,  the  nerve  of  vision.  (See  pp. 
138-144  and  154-1.59.) 

Third  Nerve — Motor  oculi — supplies  directly,  or  through 
the  lenticular  ganglion,  the  sphincter  muscle  of  the  iris,  the 
ciliary  muscle,  the  levator  palpebrag,  and  all  the  muscles  of 
the  eyeball  except  the  superior  oblique  and  external  rectus. 
Tliese  muscles  should  be  tested  separately.  (See  pp.  128- 
138  and  154,  155.) 

Fourth  Nerve — Patheticus,  Trochlearis — supplies  the 
superior  oblique  muscle  of  the  eye.  (See  pp.  133-135,  and 
155.) 

Fifth  Nerve — Trifacial,  Trigeminal — is  partly  motor, 
but  its  largest  part  is  purely  sensory.  The  motor  branches 
ai'e  derived  from  the  small  root  of  the  nerve.  These  motor 
branches  are  all  given  off  from  the  inferior  maxillary  portion. 
They  are  distributed  chiefly  to  the  muscles  of  mastication, 
viz.,  the  temporal,  masseter,  and  internal  and  external  ptery- 
goids ;  the  mylo-hyoid,  and  the  anterior  belly  of  the  digas- 
tric, likewise,  are  supplied  from  this  source.  The  power  of 
closing  the  jaw  perfectly,  and  of  moving  it  laterally,  affords 
evidence  of  the  soundness  of  these  branches.  Tiie  buccinator 
muscle  was  formerly  supposed  to  be  supplied  by  the  fifth, 
but  it  is  now  recognized  that  the  buccal  branch  of  this  nerve 
is  sensory,  and  that  the  motor  supply  comes  from  the  seventh. 
The  motor  branches  from  Meckel's  ganglion  going  to  the 
palate  and  uvula  are  supposed  to  be  derived  from  the  seventh 
nerve.  The  sensory  branches  supply  common  tactile  sensa- 
tion to  the  skin  of  the  face  from  the  forehead  to  the  chin,  to 
the  mucous  surfaces  of  the  mouth,  tongue,  palate,  and  uvula  ; 
the  conjunctiva,  the  mucous  membrane  of  nose,  and  the  teeth 
are  all  supplied  from  this  source.  In  addition,  the  lingual 
or  gustatory  branch  supplies  probably  some  portion  of  the 
special  sense  of  the  tongue,  (apart  even  from  the  fibres  of  the 
chorda  tympani   nerve   mechanically  united  with  it).     The 

14* 


162  TESTING    OP    CRANIAL    NERVES. 

fifth  nerve  has,  moreover,  very  important  functions  connected 
with  the  nutrition  of  the  eyeball,  of  the  hairs,  and  other  parts 
to  which  it  is  supplied.  When  affected  as  far  back  as  the 
Glasserian  ganglion,  sloughing  of  the  cornea,  and  other  tro- 
phic changes  have  been  observed.  The  tests  applied  in  judg- 
ing of  the  sensory  branches  of  this  nerve  are  by  means  of 
the  compasses  for  the  common  tactile  sense  of  the  skin, 
tongue,  and  lips  ;  by  tickling  the  palate  or  uvula  for  the  pro- 
duction of  reflex  action,  acting  on  one  side  only  at  a  time  ; 
by  test  solutions  for  the  special  sense  of  the  tongue  (see  Taste, 
p.  148)  ;  and  by  examination  of  the  clearness  of  the  cornea, 
the  color  of  the  eyebrows,  the  amount  and  character  of  the 
secretions  of  the  nostrils,  &c.,  for  any  trophic  changes  in 
affections  of  this  nerve.  Pain  or  neuralgia  in  the  situations 
enumerated  above  may  be  referred  to  this  nerve. 

Sixth  Nerve — Abducens  oculi — supplies  only  the  exter- 
nal rectus  of  the  eye.  Deficiency  in  the  power  to  move  the 
eyeball  outwai'ds  is  the  sign  of  paralysis  of  this  nerve,  but 
care  must  be  taken  to  ascertain  that  the  eyaball  is  not  fixed 
from  inflammation,  abscess,  or  tumor  of  the  orbit.  In 
slighter  forms,  diplopia  may  be  the  only  evidence  of  this 
paralysis.     (See  pp.  129-135  and  154.) 

Seventh  Nerve  (Portio  Dura) — Facial This  nerve 

is  essentially  motor,  but  some  communicating  branches  are 
still  involved  in  doubt  as  to  their  exact  function.  The  mus- 
cles directly  supplied  include  all  the  great  muscles  of  expres- 
sion, and  in  judging  of  their  healthy  or  paralyzed  condition, 
it  is  desirable  to  get  the  patient  to  laugh,  to  whistle,  or  to 
simulate  expressions  of  surprise,  &c.  These  muscles  include 
those  of  the  external  ear,  the  occipito-frontalis,  corrugalor 
supercilii,  orbicularis  palpebrarum,  the  muscles  of  the  nose, 
cheek,  upper  and  lower  lips,  the  orbicularis  oris,  buccinator, 
stylo-hyoid,  part  of  the  platysma,  and  the  posterior  belly  of 
the  digastric.  In  addition  to  these,  the  facial  sends  a  branch 
to  Meckel's  ganglion — the  large  superficial  petrosal  nerve — 
and  it  is  probably  from  this  source  that  the  motor  supply  of 
the  azygos  uvulas  and  the  levator  palati  is  derived.  The 
facial,  moreover,  sends  a  branch — the  chorda  tympani — to 
join  the  lingual  or  gustatory  of  the  fifth  ;  and  it  is  now  gene- 
rally agreed  that  the  chorda  tympani  supplies  the  sense  of 
taste  in  the  anterior  part  of  the  tongue  (see  Taste,  p.  148). 
The  facial  also  supplies  the  intrinsic  muscles  of  the  tongue 
(lingualis). 

In  examining  cases  of  paralysis  of  the  portio  dura,  atten- 


CRANIAL    NERYES — SEVENTH.  163 

tion  should  be  specially  directed  to  the  occipito-frontalis-and 
the  orbicularis  palpebrarum  ;  these  are  usually  paralyzed  to 
a  marked  extent  in  lesions  atFecting  the  trunk  of  the  nerve, 
so  that  the  eye  often  remains  uncovered  and  waters  readily, 
or  even  becomes  seriously  affected  from  exposure.  These 
muscles  often  escape  in  large  part  in  the  facial  paralysis  due 
to  general  cerebral  causes  (hemiplegia).  The  mouth  is 
usually  also  badly  affected  in  lesions  of  the  trunk  of  the 
seventh,  so  that  the  patient  cannot  whistle,  and  from  paraly- 
sis of  the  orbicularis  oris  the  saliva  may  escape :  from  the 
flabby  state  of  the  buccinator,  the  food  often  accumulates 
helplessly  between  the  cheek  and  the  teeth.  All  these  symp- 
toms are  usually  much  more  marked  in  cases  of  paralysis 
from  peripheral  causes  than  in  those  from  central  affections. 
Deviation  of  the  uvula  or  unilateral  paralysis  of  the  palate 
sometimes  leads  to  a  diagnosis  of  a  lesion  behind  the  origin 
of  the  petrosal  branch  in  the  tympanum  (the  nervus  petrosus 
superficialis  major  arises  at  the  iutumescentia  gangliformis). 
The  palate  hangs  loosely  on  the  paralyzed  side,  and  its  reflex 
movements  are  lessened  :  it  may  also  be  drawn  to  the  sound 
side.  The  uvula  sometimes  deviates  to  the  paralyzed  side, 
sometimes  to  the  sound  side.  It  is  not  always  quite  even  in 
the  healthy  state.  (Its  deviation  to  the  paralyzed  side  has 
been  explained  by  the  unopposed  action  of  the  pharyngo- 
palatine  muscle.)  Paralysis  of  the  seventh  nerve  may  affect 
the  movements  of  the  tip  of  the  tongue,  especially  the  point- 
ing of  it  or  the  moving  of  the  tip  in  various  directions  when 
protruded.  It  is  also  quite  certain  that  some  loss  of  taste 
occasionally  exists  in  the  anterior  part  of  the  tongue  in  peri- 
pheral paralysis  of  the  facial  nerve.  The  hearing  should  be 
tested  carefully  in  paralysis  of  the  portio  dura. 

Facial  paralysis  sometimes  exists  on  both  sides  (bilateral 
or  double  facial  paralysis).  In  such  cases  the  face  is  sym- 
metrical but  expressionless.  It  may  arise  from  a  combina- 
tion of  right  and  left  aural  disease,  or  from  accidental 
combinations  of  other  peripheral  forms  of  facial  paralysis. 
It  is  most  commonly,  however,  due  to  disease  in  the  pons 
Varolii  or  medulla  oblongata,  and  constitutes  in  this  way  a 
feature  of  progressive  bulbar  paralysis.  (Glosso-labio-la- 
ryngeal  Paralysis.) 

Setexth  Nerve  (Portio  Mollis) — Auditory. — This 
nerve  is  purely  auditory :  disorders  in  it  show  themselves  by 
deafness,  noises  in  the  ear,  and  occasionally  vertigo  (see  pp. 
144  and  1.58). 


164  TESTING    OF    CRANIAL    NERVES. 

Eighth  jS^erve  —  Glosso-Pharyxgeal  —  is  almost 
purely  sensory ;  it  supplies  sensation  to  the  tonsils  and  phar- 
ynx, and  so  is  greatly  concerned  in  the  reflex  actions  of 
swallowing  :  it  supplies  the  back  part  and  the  sides  of  the 
tongue  with  special  sensation,  and  is  distributed  to  the  cir- 
cumvallate  papillae.  It  supplies  the  mucous  membrane  of 
the  tympanum  and  Eustachian  tube  with  sensory  fibi-es.  It 
may  be  tested  by  attempting  to  produce  reflex  actions,  by 
tickling  the  pharynx,  and  by  test  solutions,  esjiecially  bitter 
fluids,  applied  to  the  back  of  the  tongue  (see  Taste,  p.  148). 

Eighth  Nerve — Spinal  Accessory — The  portion  of 
this  nerve  which  arises  from  the  medulla  oblongata  (bulbar 
portion)  seems  to  be  distinct  in  function  from  that  arising 
from  the  spinal  cord.  Both  roots  ai'e  purely  motor.  The 
fibres  from  the  former  enter  the  branch  communicating  with 
the  pneumogastric,  and  are  distributed  to  the  muscles  of  the 
pharynx  and  larynx  (through  the  superior  and  recurrent 
laryngeal  nerves).  The  fibres  derived  from  the  spinal  por- 
tion of  tlte  nerve  are  distributed  to  the  sterno-mastoid  and 
trapezius  muscles.  Disorder  of  the  roots  of  the  spinal 
accessory  nerve  may  therefore  give  rise  to  laryngeal  and 
pharyngeal  disorders,  or  to  convulsive  or  other  affections  of 
the  trapezius  or  sterno-mastoid. 

[Laryngeal  disorders  may  also  arise  from  affections  of  the 
recurrent  laryngeal  nerve,  due  to  aneurismal  or  other  tumors 
in  chest.  Glosso-labio-laryngeal  paralysis  is  probably  asso- 
ciated with,  and  in  part  due  to,  an  affection  of  this  nerve.] 

Eighth    Nerve  —  Pneumogastric This  nerve    has 

such  a  wide  distribution,  such  important  connections  with 
other  nerves,  especially  the  sympathetic,  and  still  remains  in 
so  much  obscurity  as  to  certain  of  its  functions,  that  no  at- 
tempt need  here  be  made  to  detail  its  sphere  of  operation. 
The  student  may  remember,  in  the  present  connection,  that 
it  supplies  the  mucous  membrane  of  the  pharynx  and  larynx, 
and  also  the  muscles  of  both,  although,  as  mentioned  in  the 
preceding  section,  this  motor  portion  is  derived  probably 
irom  the  spinal  accessory.  The  thyroid  gland  also  derives 
its  supply  from  the  pneumogastric  ;  and  the  heart,  lungs, 
oesophagus,  stomach,  bowels,  liver,  and  spleen  all  receive 
important  nervous  filaments,  either  directly  from  this  nerve, 
or  from  the  cardiac,  pulmonary,  and  other  plexuses  to  which 
it  gives  branches.  Aphonia,  dysphagia,  vomiting,  constipa- 
tion, palpitation,  intermittent  pulse,  hepatic  disorder  (in- 
cluding   diabetes),   and   respiratory   disorders   and   distress, 


CRANIAL    NERVES — NINTH.  165 

may  all,  at  times,  be  referred  with  more  or  less  probability 
to  an  affection  of  this  nerve  in  some  part  of  its  course. 

Ninth  Nerve — Hypoglossal — is  purely  motor.  It  sup- 
plies all  the  depressor  muscles  of  the  hyoid  bone,  receiving 
some  important  fibres  from  the  second  and  third  cervical 
nerves  through  the  communicans  noni.  The  genio-hyoid 
and  the  omo-hyoid  are  also  supplied  from  the  same  source. 
It  also  supplies  the  (extrinsic)  muscles  which  act  on  the 
tongue,  and  it  even  gives  a  few  terminal  fibres  to  its  intrinsic 
muscles  (lingualis).  This  nerve,  therefore,  is  concerned  in 
deglutition  and  in  the  movements  of  the  tongue.  Paralysis 
of  this  nerve  on  one  side  leads  to  protrusion  of  the  tongue 
towards  the  paralyzed  side,  from  the  unopposed  action  of  the 
sound  genio-hyo-glossus.  If  extreme,  as  in  cases  of  injury, 
the  paralyzed  side  is  fiabby  and  falls  into  wrinkles,  but  there 
is  no  loss  of  tactile  or  gustatory  sense.  The  tongue  is  usually 
deviated  to  one  side  from  affection  of  this  nerve  in  hemi- 
plegia, and  in  glosso-labio-laryngeal  paralysis  the  ninth 
nerves  are  clearly  involved. 


1G6 


CHAPTER  VI. 

SYMPTOMS  OF  DISORDER  IN  THE  NERVOUS 

SYSTEM.' 

PARALYSIS. 

Paralysis  is  usually  understood  to  mean  a  loss  or  dimi- 
nution of  motor  power ;  occasionally  the  term  is  applied  to 
sensory  as  well  as  motor  nerves,  in  which  case  some  lesion 
of  the  function  is  signified. 

The  distrihution  of  the  paralysis  is  one  of  the  first  points 
to  be  investigated.  "  Hemiplegia"  is  the  name  given  to  a 
paralysis  of  one  lateral  half  of  the  body,  especially  of  one 
arm,  one  leg,  and  one  half  of  the  face ;  the  paralysis  of  the 
face  is  usually  on  the  same  side  as  that  of  the  limbs  ;  when 
it  is  on  the  opposite  side  it  is  termed  "alternate  hemiplegia," 
or  ''  crossed  paralysis."  "  Paraplegia"  is  technically  ap- 
plied to  a  paralysis  of  the  lower  part  of  the  body ;  the  legs 
and  the  lower  part  of  the  trunk,  including  at  times  the  blad- 
der and  rectum,  are  the  parts  usually  affected.  "  Mono- 
plegia" is  a  term  applied  to  paralysis  of  one  limb.  Paralysis 
is  sometimes  limited  to  the  lower  limbs  or  even  to  the  parts 
below  the  knee,  to  the  arms,  or  to  the  forearms  (especially 
in  cases  of  infantile  paralysis,  lead  poisoning,  wasting  palsy, 
and  traumatic  paralysis).  Paralysis  of  the  face  often  exists 
without  any  affection  of  the  limbs  ;  it  is  usually  one-sided, 
but  occasionally  double.  (See  Paralysis  of  portio  dura,  p. 
162.) 

Beyond  these  obvious  distinctions  we  must  be  on  the  watch 
for  more  definite  anatomical  and  physiological  variations  in 

'  The  following  works  are  specially  valuable  for  consultation. 
Some  of  those  referred  to  in  last  chapter  are  likewise  important. 
Reynolds's  System,  Vol.  II.,  Trousseau,  Vol.  I.,  Ziemssen's  Cyclo- 
paedia, Vols.  XL,  XII.,  XIIL,  and  XIV.;  also  West  and  other  writers 
on  Diseases  of  Children ;  Duchenne's  Treatise  on  Electricity  con- 
tains many  important  chapters,  particularly  on  Ataxy  and  various 
forms  of  atrophic  and  pseudo-hypertrophic  paralysis.  See  also 
Hammond,  Althaus,  Charcot,  Mitchell,  Bateman. 


PARALYSIS.  167 

the  distribution  of  the  paralysis ;  thus  we  have  affections  of 
single  nerves  (as  the  sixth),  or  of  special  divisions  of  a  nerve 
as  in  the  case  of  the  third  cranial  nerve  (see  pp.  135,  161), 
or  of  the  musculo-spiral  nerve  and  the  like.  Or  we  maj 
have  special  muscles  or  groups  of  muscles  paralyzed,  as  in 
the  case  of  the  deltoid,  and  the  muscles  of  the  thumb  in  mus- 
cular atrophy  ;  and  of  the  extensors  of  the  forearm,  with  the 
immunity  of  the  supinator  longus,  in  lead  paralysis.  Again, 
the  distribution  of  the  paralysis  may  affect  special  processes, 
as  in  paralysis  of  deglutition,  articulation,  &c.,  —  various 
nerves  and  muscles  being  implicated  together. 

The  delicate  exercise  and  co-ordination  of  the  movements 
required  in  the  complex  use  of  the  vocal  organs,  of  the  hand 
in  writing,  and  of  the  feet  and  legs  in  walking,  may  be 
greatly  impaired  in  cases  Avhere  paralysis  in  its  ordinary 
sense  of  want  of  motor  power  can  scarcely  be  affirmed.  vSuch 
a  condition  is  observed  in  locomotor  ataxy,  general  paralysis 
of  the  insane,  writer's  cramp,  shaking  palsy,  and  some  other 
affections. 

The  state  of  the  patient  as  to  intelligence,  and  his  general 
mental  and  emotional  condition,  are  to  be  noticed  particu- 
larly in  the  examination  ;  they  are  likewise  to  be  considered 
in  connection  with  the  previous  history  of  such  paralytic  at- 
tacks. This  inquiry  is  of  special  weight  in  cases  of  hemi- 
plegia, of  paralysis  of  the  cranial  nerves,  and  in  general  para- 
lysis of  the  insane.  It  is  evident  also  that  we  must  ascertain 
how  far  the  mental  condition  of  our  patient  can  be  relied  on 
before  we  submit  him  to  tests,  the  value  of  which  turns 
largely  on  his  intelligent  co-operation.  We  seek  to  know 
if  any  period  of  unconsciousness  occurred  in  connection  with 
the  paralysis,  and  at  Avhat  stage  of  the  illness  it  supervened, 
what  warning  was  given  of  the  attack  by  headache,  sickness, 
giddiness,  or  the  like,  what  was  the  depth  of  the  unconscious- 
ness and  the  period  of  its  duration,  whether  it  was  associated 
with  convulsions,  of  what  kind  these  were,  whether  the  un- 
consciousness had  passed  away  or  still  continued  to  any  ex- 
tent. (For  observing  paralysis  in  unconscious  states,  see 
Fits;  Sudden  paralysis,  p.  194.)  We  have  often  to  inquire, 
moreover,  whether  the  intelligence  was  affected  before  the 
paralytic  attack,  or  during  its  onset,  or  only  since  its  estab- 
lishment. We  must  test  the  intelligence,  by  questioning  the 
patient  on  subjects  with  wliich  he  is  known  to  have  been 
familiar,  or  we  may  have  to  take  the  opinion  of  his  friends 
on  this  point. 


168  DISORDERS    OP    NERVOUS    SYSTEM. 

Associated  with  more  or  less  diminution  of  the  intelli- 
gence, and  occasionally  without  any  indication  of  M'eakness 
in  this  respect,  we  observe  in  some  forms  of  paralysis  an  ex- 
cessive mobility  of  the  emotional  nature,  manifesting  itself 
in  some  patients  by  weeping,  and  in  otliers  by  laughing 
without  any  adequate  cause  ;  in  some  there  are  alternations 
of  both  conditions.  Irritability  of  the  temper,  and  very 
great  changes  in  the  moral  character,  not  unfrequently  date 
from  paralytic  attacks. 

The  sensations  of  the  shin  are  often  affected — sometimes 
impaired  and  sometimes  perverted.  (For  tests  of  anassthe- 
sia,  see  Organs  of  Sense,  p.  150  ;  and  for  perverted  sensa- 
tions, see  Subjective  disorders  of  same,  p.  160.)  When 
sensation  is  intact  this  should  be  mentioned.  AVhen  an 
affection  of  the  sensibility  can  be  determined,  this  should  be 
defined  as  to  its  distribution,  and  compared  with  the  distri- 
bution of  the  paralysis ;  in  some  regions,  as  in  the  case  of 
the  abdomen,  we  are  able  to  form  a  more  accurate  notion  of 
the  level  of  a  spinal  lesion  by  considering  the  range  of  the 
anaesthesia  than  by  merely  considering  the  range  of  the  par- 
alysis. When  this  affection  is  limited  to  one  lateral  half  of 
the  body,  it  is  termed  "  hemi-ana^sthesia;"  this  is  compar- 
tively  a  rare  occurrence  in  hemiplegia,  and  of  much  diagnos- 
tic importance  when  present.  Hemi-antesthesia  may  also 
exist  without  muscular  paralysis.     (Compare  p.  152.) 

The  limitation  of  anaesthesia  to  the  area  supplied  by  a 
particular  nerve,  as  in  the  case  of  the  fifth  nerve,  is  of  great 
diagnostic  value ;  this  may  concur  with  paralysis  of  the 
muscles  of  mastication  supplied  by  the  same  nerve.  Similar 
combinations  of  anaesthesia  and  paralysis,  in  the  regions  sup- 
plied by  special  nerves,  nerve  trunks,  or  plexuses,  may  be 
seen  in  various  affections,  especially  in  traumatic  cases,  and, 
as  already  mentioned,  in  serious  lesions  of  the  cord. 

Paralysis  often  exists  to  a  marked  extent  without  anaes- 
thesia, or  with  little  alteration  as  regards  sensation.  In 
ordinaiy  hemiplegia,  well-marked  anaesthesia  is  rare.  Even 
in  many  cases  of  paraplegia  the  anaesthesia  is  slight.  In 
infantile  paralysis  the  sensation  is  almost  invariably  pre- 
served, and  the  same  may  be  said  of  lead  palsy. 

Pain  and  Paralysis  are  sometimes  combined.  In  such 
cases  we  must  first  ascertain,  if  possible,  whether  the  appar- 
ent paralysis  may  not  really  be  due  to  the  pain.  In  severe 
neuralgia  of  the  face,  or  of  a  limb,  or  in  pain  from  diseased 
joints  and  the  like,  the  parts  cannot  be  moved  on  account  of 


STATE    OP    MUSCLES    AND    LIMBS.  169 

the  commanding  nature  of  the  pain  ;  in  cases  of  muscular 
pain,  as  in  a  stiff  neck,  the  absence  of  motion  is  no  doubt 
partly  of  this  nature  ;  in  certain  forms  of  what  is  termed 
"  rheumatic  paralysis,"  however,  the  inability  to  move  the 
part  affected  seems  to  be  partly  owing  to  this  pain  and  partly 
to  a  rheumatic  affection  of  the  nerves  or  their  sheaths  im- 
pairing their  function.  When  the  pain  in  paralysis  is  not 
of  this  character,  we  ascertain  if  the  muscles  of  the  affected 
limb  are  tender  on  pressure,  or  if  the  pains  come  in  severe 
darts  of  momentary  duration,  or,  if  they  are  associated  with 
cramps,  permanent  contractions,  or  startings  of  the  limbs. 
Thus  cerebral  meningitis  is  often  associated  at  its  commence- 
ment with  a  generalized  hyperiBSthesia,  and  this  is  likewise 
noticeable  in  some  cases  of  hemiplegia  ;  spinal  meningitis,  by 
its  attendant  pains,  may  simulate  rheumatism ;  lesions  of 
the  cord  may  give  rise  to  pains  reseml)ling  sciatica  and  other 
forms  of  neuralgia,  and  "  electric"  or  "toothache-like"  pains 
in  the  legs  are  habitual  in  locomotor  ataxy ;  the  pain  at  the 
beginning  of  infantile  paralysis  may  be  such  as  to  give  rise 
to  a  suspicion  of  hip  joint  diseases  ;  pains  of  various  degrees 
of  intensity  occur  likewise  in  wasting  palsy. 

The  condition  of  the  paralyzed  limbs  and  muscles  must 
be  ascertained.  Differences  in  thickness  and  in  temperature 
are  often  found  even  in  recent  cases  of  the  atrophic  paralysis 
of  infants,  and  in  old  cases  of  various  forms  of  paralysis. 
Occasionally  a  relative  increase  of  temperature  can  be  made 
out  in  the  paralyzed  limbs  in  the  early  stage  of  hemiplegia, 
but  a  slight  difference  in  the  opposite  direction  is  much  com- 
moner later  on.  The  muscles  are  to  be  examined  as  to  their 
bulk ;  we  look  to  see  whether  they  are  apparently  larger 
(pseudo-hyper trophic  muscular  paralysis)  or  smaller  and 
softer  than  natural,  and  in  judging  of  this  we  must  allow  for 
the  changes  brought  about  by  disuse  from  any  cause;  wast- 
ing is  specially  noticeable  in  cases  of  mechanical  injury  of 
the  nerves,  in  wasting  palsy,  infantile  paralysis,  and  certain 
other  forms  of  spinal  paralysis.  Small  fragments  of  muscle 
have  been  sometimes  removed  by  Duchenne's  emporte-piece 
histologique  to  ascertain  whether  the  muscular  fibres  have 
undergone  fatty  degeneration,  or  have  been  replaced  by 
fibrous  tissue.  We  also  examine  the  muscles  as  to  the  power 
remaining  in  them  ;  the  dynamometer  is  sometimes  useful  in 
recording  the  force,  especially  as  a  test  of  improvement  or 
deterioration  in  this  respect;  considerable  variations  occur 
with  the  dynamometer  from  the  varying  tact  employed  by 
15 


170  DISORDERS    OF    NERVOUS    SYSTEM. 

the  patients  in  using  it.  Grasping  the  fingers  of  the  ob- 
servei-,  pushing  tlie  foot  against  one's  hand,  raising  the  arm 
into  certain  positions,  and  holding  out  weights,  «S:c.,  may  be 
mentioned  as  rough  tests  of  the  muscular  power.  Coarse 
trials  of  mere  strength  like  tliese  may  fail  to  reveal  defects 
in  the  more  delicate  exercise  and  adjustment  of  the  muscles 
required  in  using  tools,  in  writing,  sewing,  &c.  Unsteadi- 
ness may  come  into  play  likewise  to  spoil  the  muscular 
movements  (see  pp.  170,  171,  and  190). 

The  electric  exploration  of  muscles  is  of  considerable 
value ;  this  is  dealt  with  in  special  section  (see  Electrical 
Instruments,  Chapter  vii.)  The  so-called  muscular  sense  is 
also  dealt  with  in  another  place  (see  Chapter  v.,  p.  153). 

The  condition  of  the  muscles  as  to  permanent  contraction, 
movements,  and  tremors  must  be  considered  in  cases  of  pa- 
ralysis. Rigidity  of  the  paralyzed  limbs  should  be  inquired 
into  as  to  whether  it  appeared  at  the  beginning  of  the  pa- 
ralysis, or  not  till  some  months  or  years  afterwards  (early  and 
late  rigidity).  Early  rigidity  denotes  a  lesion  giving  rise  to 
iri-itation  of  the  motor  ganglia,  and  is  often  associated  with 
lesions  of  the  cortical  portions  of  the  brain,  including  its 
membranes,  and  with  certain  forms  of  spinal  meningitis. 
Late  rigidity  depends  probably  on  changes  induced  by  the 
contraction  of  nervous  tissue  during  the  cicatricial  process. 
We  must  try  whether  we  can  stretch  out  the  rigid  limbs, 
and  whether  this  causes  pain;  also  whether  any  involuntaiy 
movements  exist  in  the  contracted  member,  whether  the  con- 
traction is  associated  with  tonic  spasm  of  the  muscles,  and 
whether  this  spasm,  if  present,  ever  gives  way  to  relaxation. 

Involuntary  movements  in  paralyzed  limbs  must  be  noted 
when  present.  In  chorea  the  erratic  movements  are  often 
complicated  with  a  certain  degree  of  paralysis.  Both  the 
movements  and  the  paralysis  are  usually  more  pronounced 
on  one  side  than  the  other.  Occasionally  the  chorea  is  lim- 
ited to  one  side  (hemichorea),  and  the  paralytic  complica- 
tion, when  present,  usually  attacks  the  side  chiefly  affected 
with  the  twitchings.  This  paralysis  generally  follows  the 
chorea,  sometimes  precedes  it.  Of  a  somewhat  similar  na- 
ture is  the  transient  hemiplegia  Avhich  sometimes  follows 
epileptic  attacks  (epileptic  hemiplegia). 

Unilateral  convulsions  sometimes  usher  in  a  hemiplegia  ; 
sometimes  such  convulsions  occur  or  recur  in  the  course  of 
the  paralysis.     Such  convulsions  may  take  place  without  loss 


CHOREA  —  ATHETOSIS — SHAKING    PALSY.         HI 

of  consciousness,  and  may  be  limited  to  a  paralyzed  arm  or 

leg- 
Paralyzed  limbs  sometimes  move  involuntarily  in  connec- 
tion with  automatic  actions,  particularly  the  arm  in  the  act 
of  yawning.  Movements  of  the  legs,  quite  involuntary,  are 
common  in  paraplegia;  where  the  spinal  cord  is  seriously 
destroyed,  these  may  be  very  marked  and  even  violent; 
they  are  often  produced  by  very  slight  irritations  acting  in 
a  reflex  manner;  occasionally  the  exciting  cause  is  plain 
enough,  as  when  the  irritation  is  from  exposure  to  the  cold 
air,  or  from  movements  of  the  bed-clothes,  &c. ;  but  some- 
times the  cause  is  not  apparent,  being  perhaps  hidden  from 
view ;  the  urinary  passages  and  the  bowels  are  no  doubt  at 
times  the  seat  of  such  hidden  irritations. 

Choreic  movements  sometimes  become  developed  in  para- 
lyzed limbs  in  hemiplegia  (post-hemiplegic  chorea) ;  these 
differ  from  Dr.  Hammond's  "  athetosis,"  as  in  this  latter  affec- 
tion there  is  no  history  of  pre-existing  hemiplegia,  although 
a  certain  loss  of  power  may  coexist  with  it.  A  minute  fibril- 
lary quivering  is  observed  sometimes  in  cases  of  muscular 
atrophy,  and  is  very  noticeable  in  the  tongue  and  lips  in 
general  [)aralysis,  delirium  tremens,  and  some  other  affections. 
A  degree  of  irregular  muscular  movement  or  tremor  is 
seen  in  certain  forms  and  stages  of  cerebral  and  cerebellar 
disease,  locomotor  ataxy,  and  general  paralysis ;  some  of 
these  peculiarities  will  be  noticed  in  the  section  on  unsteadi- 
ness in  balancing  the  body,  and  in  walking ;  such  complex 
efforts  bring  out  tlie  deflciency  in  a  marked  manner.  (See 
}).  172.)  It  must  not  be  forgotten  that  simple  weakness 
renders  the  limbs  unsteady  as  well  as  feeble,  and  various 
febrile  states  intensify  the  trembling  as  well  as  the  weakness 
(delirium  tremens,  typhus,  &c.). 

Shaking  of  the  paralyzed  li)nhs  is  not  uncommon  in  hemi- 
plegia, tremulous  vibrations  differing  from  choreic  movements 
in  being  somewhat  rhythmical  in  their  character  and  much 
more  limited  in  their  nature  ;  this  general  shaking  of  the 
whole  limb  resembles  that  which  occurs  after  an  unwonted 
muscular  effect.  We  may  have  this  shaking  developed  with- 
out any  preceding  hemiplegia  or  paralysis,  although  when 
established  it  amounts  to  a  virtual  y)aralysis,  and  is  named 
"Pai'alysis  Agitans,"  or  "Shaking  Palsy."  Such  shaking  is 
often  unilateral ;  sometimes  it  affects  only  one  limb  ;  some- 
times the  head  is  notably  affected  with  similar  shaking  or 
noddina:    movements.     Along  with    this    shaking   we    often 


172  DISORDERS    OF    NERVOUS    SYSTEM. 

observe  emotional  disturbances,  and  sometimes  that  peculiar 
gait  termed  "festination,"  in  which  tlie  jjatient  has  to  hurry 
on  to  keep  himself"  from  tumbling  forwards,  always  "in  pur- 
suit of  his  centre  of  gravity,"  as  has  been  said.  Such  affec- 
tions are  commonest  in  the  aged,  or  those  past  middle  life  ; 
but  a  similar  afl'ection,  due  to  cerebral  or  spinal  sclerosis,  is 
sometimes  seen  in  young  persons.  "  Nodding  convulsions," 
with  nodding,  bending,  rotating,  or  bowing  of  the  head  or 
of  the  body,  constitute  a  rare  disease  observed  in  young 
children  ;  it  is  described  al?o  under  the  names  of  "Eclamp- 
sia nutans,"  and  "  Salaam  convulsions." 

Somewhat  intermediate  between  chorea-like  movements 
and  shaking  palsy  are  the  tremors  seen  in  mercurial  para- 
lysis, and  some  other  Ibrms  of  metallic  poisoning.  The  occu- 
pation of  the  patients,  and  the  existence  of  salivation,  &c., 
assist  us  in  the  diagnosis. 

Reflex  action  in  paralyzed  limbs  accounts,  as  already  indi- 
cated, for  many  involuntary  movements  in  the  parts,  but  we 
may  have  to  produce  it  experimentally  by  tickling  the  soles 
of  the  feet,  and  by  similar  irritations,  avoiding  painful  im- 
pressions. Eeflex  action  is  often  jjreserved  and  even  much 
heightened  when  the  cord  is  seriously  destroyed  in  a  limited 
])art  of  its  coui-se.  This  excessive  action  is  probably  due  to 
the  controlling  influence  of  the  brain  being  cut  off.  When 
reflex  action  is  preserved,  we  infer  the  essential  integrity  of 
the  cord  at  the  part  where  the  afl'erent  and  efferent  nerves 
concerned  in  the  experiment  enter  tl;e  spinal  cord.  The 
reflex  action  may  be  perfect  although  there  is  complete  loss 
of  sensation.  When  the  reflex  action  is  preserved  the  nutri- 
tion and  electric  condition  of  the  muscles  are  usually  but 
little  impaired. 

Walking  and  Balancing   in   Paralysis The  power  of 

balancing  the  body  varies  ranch  in  different  forms  of  para- 
lysis, and  it  is  sometimes  very  deficient  in  cases  where  the 
loss  of  muscular  power  is  but  slight.  This  want  of  power 
in  balancing  often  comes  out  Avhen  the  patient  tries  to  walk. 
In  children  the  complaint  of  inability  to  walk  is  sometimes 
made  when  the  real  defect  is  in  the  intelligence  (idiocy). 
Lateness  of  walking  in  children  often  arises  from  a  genei'al 
defect  due  to  rickets,  apart  from  any  true  paralysis.  The 
manner  of  walking  must  always  be  scrutinized  in  cases  of 
paralysis.  In  hemiplegia  the  paralyzed  leg  is  often  swung 
round  from  the  trunk,  and  the  toe  of  tlie  paralyzed  leg  may 
drag  or  scrape  as  it  goes  along,  so  that  it  makes  a  mark,  for 


UNSTEADINESS    IN    WALKING.  113 

example,  on  a  gravel  walk.  When  infantile  paralysis  affects 
one  of  the  lower  limbs,  the  chief  deficiency  is  almost  inva- 
riably below  the  knee,  and  when  the  loss  of  power  is  not 
extreme,  the  foot  is  swung  round  or  "  thi-own,"  as  the  pa- 
rents say,  in  a  very  characteristic  manner.  In  paraplegia 
the  feet  may  almost  be  said  to  be  trailed  along  when  the 
paralysis  is  considerable  ;  when  one  leg  is  worse  than  the 
other  this  trailing  often  serves  to  distinguish  it.  In  less 
severe  cases  the  feet  and  legs  are  lifted  with  an  obvious  ef- 
fort. We  must  also  notice  whether  the  patient  walks  on  his 
toes,  from  spasm  or  contraction  of  the  muscles  and  tendons 
of  the  calf  of  the  leg,  or  on  the  side  of  the  foot,  from  partial 
paralysis  of  special  groups  of  muscles,  or,  more  rarely,  on  the 
heel  from  a  similar  cause.  The  hurrying  gait,  known  as 
"  festination,"  already  mentioned,  may  exist  in  all  degrees 
from  a  slight  hurrying  and,  a  slight  difficulty  in  stopping,  up 
to  the  most  extreme  running  and  staggering  forward  in  a 
way  that  is  quite  alarming. 

Staggering  in  a  most  extreme  form  is  often  found  in  dis- 
ease of  the  cerebellum,  so  that  the  patient  in  a  bad  case  can- 
not make  a  few  steps  forward  without  staggering  to  the  one 
side.  Similar  deviation  to  the  one  side  is  one  of  the  symp- 
toms in  Meniere's  disease.     (See  p.  159.) 

In  locomotor  ataxy  and  in  general  paralysis  there  is  fre- 
quently very  marked  unsteadiness  in  walking  and  standing, 
but  special  tests  require  to  be  applied  in  some  cases  to  bring 
this  out.  We  ask  the  patient  to  walk  along  a  given  line ; 
the  seam  of  a  carpet  or  a  plank  of  the  floor  answers  for  this 
purpose.  Or  we  ask  him  to  put  his  feet  together  and  to 
stand  still ;  or  we  ask  him  to  stand  on  one  foot  and  then  on 
the  other.  In  ordinary  paraplegia  when  the  patient  gets 
fairly  in  the  erect  position  he  can  often  stand  very  firmly ; 
any  deficiency  in  this  respect  usually  arises  from  tlie  knees 
giving  way  from  muscular  weakness,  and  with  care  in  ad- 
justing himself  such  a  person  can  even  stand  on  a  single 
foot.  In  locomotor  ataxy  this  power  is  remarkably  dimin- 
ished. A  patient  who  can  walk  fairly  is  unable  to  stand 
steadily,  he  cannot  get  a  "  grip  of  the  ground,"  he  says,  and 
requires  to  spread  out  his  feet  and  to  keep  a  strict  watch 
with  his  eyes  on  the  ground.  This  relationship  of  the  siglit 
to  the  power  of  balancing  must  be  specially  considered  in 
cases  of  suspected  ataxy.  It  comes  out  to  its  greatest  extent 
when  the  patient  puts  his  feet  close  together  and  tries  to 
balance  himself  with  his  eyes  shut ;  a  good  method  of  test- 

15* 


1*14  DISORDERS    or    NERVOUS    SYSTEM. 

ing,  especially  with  the  view  of  tracing  any  improvement  or 
deter ioi'ati on,  is  to  count  the  number  of  seconds  during  which 
such  a  {tatient  can  thus  remain;  care  must  be  taken  to  have 
assistance  at  hand,  not  only  to  prevent  actual  accidents,  but 
also  to  give  the  patient  a  i'eeling  of  security  in  submitting 
to  the  test.  A  further  indication  of  the  importance  of  the 
eyesight  in  balancing  comes  out  in  the  event  of  the  patient 
having  to  walk  in  tlie  dark,  «r,  as  ha])pens  in  certain  cases, 
in  the  event  of  blindness  coming  on  ;  we  may  also  apply  the 
test  by  seeing  how  he  can  walk  while  looking  up  towards  the 
roof  instead  of  at  his  feet.  The  least  catch  of  anything  often 
assists  wonderfully  in  steadying  the  patient  in  this  condition, 
the  hand,  like  the  eye,  coming  to  the  assistance  of  the  lower 
limbs.  A  further  peculiarity  in  the  walking  of  such  patients 
consists  in  the  way  in  which  they  very  often  raise  their  feet 
much  higher  than  is  requisite,  and  stamp  them  down  with 
unnecessary  force.  All  these  peculiarities  seem  to  depend 
in  part  on  the  diminished  sensibility  of  the  skin  of  the  feet, 
but  chiefly  on  a  want  of  the  delicate  adjustments  of  the  force 
in  the  various  muscles  required  for  a  particular  effoi't.  A 
further  test  is  supplied  by  the  act  of  turning  round  while 
walking  back  and  forward.  Deflciency  in  this  respect  ap- 
pears in  many  cases  of  general  paralysis  also. 

Various  defects  in  walking  appear  in  connection  with  other 
aifections  as  well  as  paralysis  proper.  The  most  important 
of  these  is  disease  of  the  joints  and  especially  of  the  hip-joint, 
so  that  we  have  often  to  scrutinize  the  symptoms,  measure  the 
limb,  and  test  for  localized  paip  by  pressure  and  percussion, 
before  coming  to  a  decision.  In  children,  particularly,  from 
there  being  often  but  little  pain,  the  distinction  between  hip- 
joint  disease  and  infantile  paralysis  is  sometimes  very  difficult 
to  establish,  and  a  similar  difficulty  arises  when  it  happens 
that  the  pains  in  the  early  stage  of  infantile  paralysis  resem- 
ble those  of  hip-joint  disease  ;  the  measurement  of  the  limb, 
the  examination  of  the  joint,  the  temperature  of  the  paralyzed 
leg,  the  electrical  state  of  the  muscles,  and  the  history  of  the 
case  must  guide  the  diagnosis.  Abscesses  of  various  kinds, 
involving  the  psoas  and  iliacus,  and  some  rheumatic  affections 
of  the  muscles,  may  give  rise  to  difficulties  in  walking  bearing 
some  resemblance  to  paralysis. 

Difficulties  as  to  Speech  require  very  special  study  in  cases 
of  paralysis.  A  patient  may  be  unable  to  speak  or  to  answer 
a  question  because  of  unconsciousness  or  impaired  intelligence 
(idiocy  or  dementia  of  any  kind)  ;  congenital  or  other  defects 


APHASIA.  175 

in  the  hearing  and  in  the  vocal  organs  need  scarcely  be  naen- 
tioned.  When  the  inability  arises  from  such  causes,  the 
general  aspect  of  the  patient  and  the  previous  history  usually 
guide  us  aright.  In  other  cases,  the  loss  of  articulate  speech 
is  associated  with  such  obvious  paralysis  of  the  tongue,  lips, 
and  palate,  that  we  can  very  safely  refer  the  loss  of  speech, 
or  the  defective  utterance,  to  this  cause.  In  such  cases  we 
must  test  the  motor  power  of  these  parts  in  various  ways. 
(See  seventh,  eiglitli,  and  ninth  nerves,  pp.  162—165.)  A 
further  assistance  is  given  in  this  matter  by  ascertaining 
which  are  the  most  impei"i"ect  sounds  ;  the  pronunciation  of 
the  labials  in  particular  is  often  affected  from  paralysis  of  the 
lips,  and  a  nasal  tone  may  be  communicated  to  the  voice 
from  paralysis  of  the  palate. 

Certain  defects  remain  which  cannot  be  explained  at  all 
in  this  way,  and  there  are  others  which  are  only  partially 
intelligible  on  such  a  view.  When  for  example  a  patient 
cannot  speak,  or  can  only  use  one  or  two  simple  words  to 
express  himself,  and  is  yet  able  to  repeat  lists  of  words,  or 
even  sentences  dictated  to  him,  it  becomes  clear  that  the 
defect  is  not  due  to  any  want  in  the  muscular  and  nervous 
apparatus  of  the  mere  orgaiiS.  This  is  equally  clear  in  those 
cases  where  the  patient's  difficulty  occurs  only  or  chiefly 
with  the  names  of  objects  and  persons.  To  the  affections  of 
speech  indicated  in  this  paragraph  the  term  "Aphasia"  is 
applied. 

Aphasia  must  be  studied  and  described  as  to  its  various 
forms.  The  patient  can  sometimes  express  liimself  quite 
correctly  in  writing,  although  unable  to  speak  ;  to  this  rare 
condition  the  term  "Aphemia"  is  now  applied  by  some.  He 
appears  sometimes  to  understand  words  addressed  to  him 
perfectly,  although  unable  to  speak,  or  at  least  to  go  beyond 
a  word  or  two.  In  other  cases  words  addressed  to  him  may 
seem  to  convey  no  meaning  at  all.  Tliis  condition  must  be 
tested  by  asking  the  patient  to  do  certain  things,  carefully 
avoiding  any  gestures  in  making  the  request.  He  may  be 
able  to  say  certain  words  or  parts  of  sentences  while  stumbling 
at  names  ;  he  may  know  when  the  right  name  for  the  object 
or  person  is  supplied  to  him,  or  he  may  supply  wrong  names, 
although  conscious  tliat  they  are  wrong,  and  quite  clear  as  to 
what  he  really  means.  He  may  be  able  to  repeat  words  and 
short  sentences  after  they  are  dictated  to  him  although  unable 
to  originate  them ;  or  to  say  parts  of  familiar  passages,  such 
as  the  Lord's  Prayer,  especially  when  this  is  started  for  him. 


IIQ  DISORDERS    OP    NERVOUS    SYSTEM. 

Aphasic  patients  have  usually  one  or  two  words,  especially 
"  yes"  and  "  no  ;"  when  they  have  only  one  of  tliese  its 
affirmative  or  negative  meaning  is  expressed  by  variations 
in  the  tone  or  otherwise.  They  have  often  certain  phrases 
and  expi'essions  wliich  are  brought  out  in  a  parrot-like  man- 
ner, although  at  times  tliey  are  deceptive  from  fitting  admi- 
rably as  answers  (e.g.^  "  I  cannot  tell").  Exclamations  of 
anger,  surprise,  &c.,  and  oaths  are  sometimes  given  utterance 
to  at  odd  times  by  those  quite  unable  to  speak  unless  thus 
surprised  into  such  emotional  expressions.  Aphasic  patients 
can  often  sing  or  hum  tunes,  although  unable  to  use  words 
or  only  to  use  a  few.  Writing  is  an  important  test  to  be 
applied  to  aphasic  patients.  A  few  can  express  themselves 
in  writing  quite  well  although  they  cannot  speak.  When 
from  [)aralysis  of  the  right  arm  the  patient  cannot  write, 
movable  letters  may  be  tried.  Various  degrees  of  ability  are 
seen  in  aphasia  in  this  respect,  but  anything  like  perfect  use 
of  writing  is  very  rare.  A  strange  medley  of  words,  or  stray 
words  and  confused  combinations  of  strokes  and  syllables,  are 
often  shown  by  aphasics  with  obvious  self-satisfaction.  Some, 
however,  can  write  words  to  dictation  who  cannot  originate 
a  written  sentence.  Many  can  write  words  and  long  sen- 
tences from  a  copy  supplied  to  them.  Some  can  copy  from 
printed  characters  into  ordinary  writing  ;  others  can  only 
copy  as  if  by  pure  imitation.  Some  can  identify  their  own 
names  or  the  names  of  friends  in  a  long  list,  whether  in 
written  or  printed  characters,*  although  they  do  not  know  the 
individual  letters  ;  tlie  general  appearance  of  the  familiar 
word  probably  guides  them.  Many  aphasics  appear  to  read 
books  with  interest — although  probably  gaining  no  idea  from 
the  process  ;  we  must  test  them  as  to  their  knowledge  of 
what  they  seem  to  be  reading.  Persistent  aphasia  may  exist 
along  with  but  little  diminution  of  high  mental  power,  but 
the  intelligence  is  usually  seriously  impaired,  even  more  than 
might  apfjear  on  a  preliminary  invest'gation. 

These  details  indicate  the  points  to  be  noted  in  connection 
with  the  study  of  the  varying  gradations  of  the  affection  in 
aphasic  patients ;  such  a  note  of  the  actual  state  is  better  than 
applying  mere  names  to  characterize  the  kind  of  aphasia,  as 
these  usually  imply  artificial  d'stinctions  and  theoretical  con- 
siderations not  fully  justified  by  the  facts.  (Aphemia,  or 
ataxic  aphasia,  loss  of  the  co-ordinating  power  implied  in 
forming  words, — writing  being  preserved ;  amnesia  or  am- 
nesic aphasia,  loss  of  the  memory  of  words,  &c.) 


APHASIA.  177 

The  clinical  fact  most  frequently  associated  with  aphasia  is 
right  hemiplegia  (in  rare  cases  there  is  left  hemiplegia;  in  the 
latter  event  we  should  inquire  if  the  patient  is  left-handed). 
Unilateral  conyulsions  and  other  evidences  of  cerebral  dis- 
turbance are  not  uncommon.  The  cerebral  disease  in  aphasia 
is,  perhaps,  most  frequently  due  to  embolism  of  the  left  middle 
cerebral  artery.  The  suddenness  and  extent  of  the  cerebral 
lesion  seem  to  play  an  important  part  in  determining  the 
occurrence  of  this  symptom,  as  well  as  the  actual  portion 
destroyed  (third  anterioi- frontal  convolution  on  the  left  side). 
When  aphasia  exists  witliout  distinct  hemiplegia,  it  may  still 
be  clearly  connected  with  cerebral  disease.  Aphasia  occurs 
sometimes  in  chorea  in  a  marked  manner,  and  much  oftener 
in  a  slight  foim;  such  attacks  of  chorea  usually  present  some 
degree  of  paralysis,  and  of  slight  dementia.  Aphasia  without 
any  history  of  paialysis  of  any  kind  is  most  commonly  ob- 
served after  severe  illnesses,  after  enteric  fever,  ibr  example, 
in  children  ;  it  is  usually  only  temporary  in  such  cases.  A 
certain  number  of  cases  of  aphasia  occur  without  definite 
paralysis,  although  the  presence  of  cerebial  disease  is  rendered 
almost  certain  by  the  existence  of  other  symptoms. 

Hie  power  of  writing  is  olten  atfected  in  paralysis ;  the 
importance  of  testing  this  has  already  been  referred  to  in 
connection  with  a])hasia.  This  concerns  the  power  to  form 
words  and  sentences,  but  even  the  mechanical  part  of  the 
handwriting  may  afford  useful  indications.  In  paralysis 
agitans,  in  general  paralysis,  and  in  the  forms  of  locomotor 
ataxy  aflecting  the  arms,  the  unsteadiness  is  shown  in  the 
writing,  and  even  when  one  cannot  observe  this  distinctly, 
there  is  sometimes  clear  proof  of  a  departure  from  the  usual 
character  of  the  writing.  This  affection  of  the  writing  varies 
considerably  at  different  times,  and  is  apt  to  be  made  worse 
by  having  the  attention  of  on-lookers  directed  to  the  writer. 
When  there  is  anoi-sthesia  of  the  fingers,  or  paralysis  of  the 
muscles  of  the  hand  and  thumb,  the  writing  is  also  apt  to  be 
affected. 

Different  from  all  these  is  the  peculiar  spasm  which  seizes 
the  fingers  in  "  writer's  cramp;"  when  the  patient  begins  to 
use  the  pen,  the  movements  soon  get  to  be  beyond  control, 
and  the  pen  cannot  even  be  held.  In  less  severe  forms  the 
spasm  only  appears  after  a  certain  amount  of  writing  has 
been  done,  and  the  difference  in  the  character  of  the  writing 
at  the  end  from  the  beginning  can  be  readily  noticed.  When 
there  is  any  form  of  affection  of  the  writing  it  is  well  to  pre- 


lis  DISORDERS    OF    NERVOUS    SYSTEM. 

serve  specimens,  containing  the  date,  for  comparison  subse- 
quently. 

Paralysis  of  the  Bladder  and  Rectu:\i  is  an  import- 
ant fact  in  cases  of  paraplegia,  and  always  constitutes  a  grave 
complication.  This  paralysis  may  show  itself  either  by 
ward  of  power  in  retaining  the  exci'etions  till  a  suitable 
opportunity  occurs  (incontinence,  paralysis  of  sphincters), 
or  in  a  want  of  power  in  expelling  the  contents  (constipa- 
tion, retention  of  urine).  It  does  not  occur  in  hysterical 
paraplegia  in  a  persistent  form,  although  occasional  retention 
of  urine  is  often  present  in  hysterical  subjects.  This  form 
of  paralysis  is  likewise  almost  unknown  in  infantile  paraly- 
sis. But  before  considering  paralysis,  properly  so  called, 
reference  may  be  made  to  conditions  which  simulate  paraly- 
sis of  these  parts.  The  presence  of  coma  or  unconsciousness 
from  any  cause,  often  leads  to  untimely  intestinal  and  urinary 
evacuations,  quite  apart  from  any  other  defect.  Similar 
causes  may  lead  to  retention  of  the  urine ;  this  is,  perhaps, 
commoner  in  the  unconsciousness  found  in  serious  febrile 
derangements,  and  in  nervous  lesions  giving  rise  to  paralysis 
of  the  nervous  centres.  Retention  of  urine  is  common  in 
connection  with  injuiy  of  the  parts,  and  after  operations  in 
the  neighborhood  of  these  organs  (severe  or  instrumental 
labor,  operations  for  piles,  &c.,  may  be  named  amongst  these). 
Such  retention  may  indeed  be  due  to  an  inhibitory  form  of 
paralysis.  Retention  of  the  urine  in  connection  witli  stricture 
or  enlarged  prostate,  although  no  doubt  partly  due  to  nervous 
spasm,  really  arises  from  distinct  mechanical  impediments. 
Dribbling  away  of  the  urine  may  be  due  to  disease  of  the 
bladder,  such  as  cystitis,  arising  from  calculus  or  other  causes ; 
it  may  also  result  from  the  organ  having  been  habitually,  or 
on  some  special  occasion,  over-distended  so  as  to  injure  the 
muscular  structures.  Involuntary  evacuation  of  feces,  apart 
from  injury  of  the  parts,  may  also  result  from  great  fluidity 
and  frequency  of  the  motions,  from  profound  debility  of  the 
patient,  or  from  anaesthesia  of  the  anal  aperture,  so  that  due 
warning  is  not  transmitted.  Such  motions  occur  also  in 
idiotic  persons.  A  form  of  local  paralysis  of  the  rectum, 
leading  to  retention  of  feces,  is  found  in  cases  of  constipation 
where  the  bowel  has  been  habitually  or  enormously  distended. 
The  condition  of  irritability  or  spasm  of  the  organs  may  lead 
to  discharge  of  the  contents  beyond  the  patient's  control. 
Dysentery,  and  other  diseases  characterized  by  tenesmus, 


ENURESIS.  179 

cystitis,  calculous  disease  of  the  bladder  and  kidney,  &c.,  may 
act  in  this  way,  apart  from  any  paralysis.  (See  Disorders  of 
defecation  and  urination.  Chapters  xi.  and  xiii.) 

Spasmodic  discharge  of  tlie  urine,  however,  also  occurs  in 
spinal  paralysis — the  bladder  contracting  on  its  contents  with 
great  force,  and  without  much  warning,  and  the  j)atieut  being 
quite  unable  to  restrain  or  delay  the  process.  A  somewhat 
similar  suddenness  and  violence  of  contraction  may  also  occur 
in  the  bowel,  by  which  the  patient  is  apt  to  be  "taken  short," 
as  he  says.  Irregular  action  in  this  way  sometimes  occurs 
in  locomotor  ataxy  as  part,  apparently,  of  the  general  inco- 
ordination. 

Wetting  the  bed  in  the  early  hours  of  night  is  often  com- 
plained of  in  the  case  of  children  (Enuresis,  Nycturia).  This 
seems  also  to  be  usually  due  to  some  form  of  spasmodic  action, 
as  it  tends  to  occur  soon  after  going  to  sleep,  and  long  before 
the  bladder  can  be  much  distended ;  indeed  it  often  only 
occurs  during  the  early  hours  of  sleep,  and  not  at  all  later 
on,  although  there  is  then  much  more  distension  ;  during  the 
day  there  is  no  urinary  trouble  in  such  cases.  This  ailment 
usually  persists  in  the  children  atfected  for  a  considerable 
time,  and  seems  due  to  some  nervous  defect.  Wetting  the 
bed  occurs  also  in  chorea.  It  sometimes  affords  an  early 
indication  of  the  occurrence  of  epileptic  fits  happening  during 
the  night.  After  enteric  fever,  and  perhaps  some  other 
acute  illnesses,  this  defect  is  occasionally  noticed  as  a  pass- 
ing fact,  in  cases  where  there  had  been  no  trouble  with  the 
bladder  during  the  height  of  the  fever.  It  occurs  especially 
in  little  girls,  and  seems  part  of  the  general  weakness,  both 
mental  and  physical,  often  found  after  this  fever. 

Paralysis  of  the  bladder  may  show  itself  by  retention,  or 
by  incontinence,  or  by  spasmodic  discharge  of  urine,  in  the 
same  case  :  beginning  as  retention,  incontinence  may  follow  ; 
or  beginning  with  an  irregular  spasmodic  action  of  the  blad- 
der, retention  or  incontinence  may  supervene. 

Paralysis  of  the  bladder  is  found  in  many  cases  of  hemi- 
plegia during  its  early  stage,  but  it  usually  passes  away  as 
the  patient  partially  recovers.  Sometimes,  however,  it  is 
permanent,  and  this  is  more  likely  to  happen  if  the  bladder 
has  been  neoflected  and  allowed  to  be  over-distended  durino- 
the  period  of  unconsciousness.  Paralysis  of  the  bladder  is 
very  common  as  part  of  the  paralysis  due  to  spinal  lesions  in 
the  lower  dorsal  or  lumbar  regions,  and  in  such  cases  it  is 
more  apt  to  be  permanent.     In  whatever  way  the  urinary 


180  DISORDERS    OF    NERVOUS    SYSTEM. 

affection  begins,  it  tends  to  the  form  characterized  by  incon- 
tinence, and  disease  of  tlie  Wadder  itseh"  (cystitis)  is  also 
often  present,  produced  partly,  perhaps,  by  distension  or  by 
the  use  of  instruments,  and  favored  by  the  alkaline  urine 
often  secreted  in  spinal  paralysis. 

A  reflex  paraplegia,  originating  from  disease  of  the  genito- 
urinary organs,  is  alleged  to  occur  sometimes,  and  in  any 
case  we  should  try  to  ascertain  the  exact  sequence  of  events ; 
serious  disease  of  the  bladder  occurring  distinctly  before  the 
paralysis  of  the  limbs  points  in  this  direction,  but  an  incipi- 
ent paralysis  may  manifest  itself  by  urinary  disturbance  as 
an  early  symptom  :  sometimes,  indeed,  an  affection  of  the 
bladder  remains  the  only  evidence  of  paralysis  for  a  long 
time. 

Paralysis  of  the  bowels  usually  manifests  itself  chiefly  as  a 
more  or  less  obstinate  constipation  ;  this  can  usually  be  over- 
come by  medicines,  but  occasionally  it  is  so  extreme  as  to 
suggest  some  serious  obstruction,  especially  when  fi*om  any 
cause  vomiting  supervenes.  The  paralysis  may  also  affect 
the  sphincters  as  already  mentioned. 

The  Clinical  Significance  of  Paralysis  in  the 
various  forms  in  which  it  appears  has  been  alluded  to  occa- 
sionally in  connection  with  special  symptoms  :  the  subject  is 
so  complex  that  reference  must  be  made  to  the  text  books 
under  such  headings  as  Hemiplegia,  Paraplegia,  Diseases  of 
the  Spinal  Cord,  &c. 

Hemiplegia  almost  invariably  implies  a  cerebral  lesion  ;  a 
few  cases  of  spinal  hemiplegia,  however,  have  been  recorded. 
When  the  face  is  involved  in  the  hemi[)legia,  the  diagnosis 
of  some  cerebral  lesion  may  be  made  with  confidence,  and 
the  lesion  is  always  on  the  side  of  the  brain  opposite  to  that 
on  which  the  limbs  are  paralyzed.  The  causes  of  the  lesion 
must  be  searched  for :  we  examine  the  state  of  the  arteries 
for  indications  of  rigidity,  of  the  cornea  for  appearances  of 
the  arcus  senilis,  and  of  the  heart  for  evidence  of  hyper- 
trophy. When  these  exist  in  a  hemiplegic  patient  not  very 
much  advanced  in  years,  they  strongly  suggest  a  hemorrha- 
gic lesion,  and  if  the  paralysis  has  been  complicated  by  the 
occurrence  of  a  fit  of  unconsciousness,  with  lividity  and 
stertor,  this  may  almost  be  regarded  as  certain.  These  re- 
marks apply  whether  there  is  any  evidence  of  chronic  disease 
of  the  kidney  or  not ;  but  the  existence  of  such  disease  ren- 
ders a  hemorrhagic  lesion  in  such  a  case  even  more  probable. 


i 


CAUSES    OP    PARALYSIS.  181 

When  there  is  valvular  disease  of  the  heart  (with  or  without 
evidence  of  hypertrophy),  we  mifst  keep  in  view  the  possi- 
bility of  embolism  :  such  attacks  are  usually  sudden,  and  may 
or  may  not  be  attended  by  unconsciousness  :  embolism  is,  on 
the  whole,  commoner  in  the  middle  cerebral  artery  of  the 
left  side  than  in  any  other  part  of  the  brain,  and  this  is  a 
frequent  cause  of  aphasia. 

The  cerebral  lesion  in  hemiplegia  may  be  of  the  nature  of 
softening ;  this  may  be  a  consequence  of  embolism,  but  may 
also  arise  from  other  forms  of  disease  in  the  vessels  (athe- 
roma, thrombosis).  Syphilitic  lesions  sometimes  give  warn- 
ing of  their  presence,  before  the  development  of  hemiplegia, 
by  affections  of  single  cranial  nerves  (third,  sixth,  and 
seventh  in  particular)  ;  these  are  sometimes  recovered  from, 
other  nerves  again  becoming  involved;  syphilitic  lesions 
often  determine  convulsions,  occurring  sometimes  in  connec- 
tion with  the  beginning  of  the  paralysis,  sometimes  before, 
and  sometimes  ai'ter  it.  Occasionally  hemiplegia  and  para- 
plegia exist  in  the  same  subject  from  syphilitic  lesions  affect- 
ing both  the  brain  and  spinal  cord  ;  the  indications  of  a 
multiple  nervous  lesion — one  not  easily  explained  by  the 
simple  growth  of  a  tumor  or  the  mere  extension  of  the  dis- 
eased condition — should  always  suggest  syi)hilis.  The  ex- 
istence of  syphilitic  nodes,  iritis,  retinitis,  &c.,  must  be 
inquired  for,  and  the  history  of  primary  sores  can  sometimes 
be  obtained  in  clearly  syphilitic  cases,  although  there  may 
have  been  no  appearance  of  secondary  symptoms  ;  in  ner- 
vous cases  the  date  of  such  infection  is  often  very  remote. 
Tumor  often  causes  paralysis  of  special  cranial  nerves  before 
hemiplegia  appears,  or  quite  apart  from  it ;  in  these  cases 
the  ophthalmoscopic  appearances  are  specially  important ; 
the  comparative  frequency  of  chronic  tubercle  of  the  brain 
and  its  membranes  must  be  remembered  in  the  case  of  chil- 
dren. Cerebral  abscess  may  produce  variable  states  of 
coma,  and  a  shifting  paralysis  of  various  cranial  nerves  ;  it 
is  frequently  indicated  by  the  occurrence  of  shiverings,  and 
sometimes  special  sources  of  purulent  infection  can  be  found 
(suppuration  of  the  tympanum,  from  disease  of  the  bones, 
from  scarlatinal  sore  throat,  &c.).  Tumor  and  cerebral 
abscess  are  both  apt  to  give  rise  to  convulsions  as  well  as  to 
hemiplegia.  Hemiplegia  occasionally  complicates  preg- 
nancy, passing  away,  it  may  be,  soon  after  delivery :  the 
urine  is  almost  always  albuminous  in  such  cases,  but  their 
pathology  still  remains  obscui'e. 
16 


182  DISORDERS    OF    NERVOUS    SYSTEM. 

Diphtheritic  Paralysis. — Paralysis  of  various  kinds,  but 
especially  of  the  palate,  arms,  and  legs,  and  of  the  accoiu- 
modation  of  the  eye,  occurs  sometimes  as  a  sequela  of  dijdi- 
theria.  It  may  be  associated  with  anaesthesia.  It  seems 
to  depend  on  a  general  poison  rather  than  on  serious  nervous 
lesions. 

Paraplegia  may  always  be  regarded  as  due  to  disease  of 
tlie  spinal  cord  or  its  membranes  ;  even  in  the  case  of  "  reflex 
]  aralysis,"  as  it  is  called,  fiom  irritation  of  the  genito-urinary 
organs,  there  is  probably  always  some  lesion  of  the  cord. 
In  hysterical  \  aralysis,  however,  which  often  assumes  the 
paraplegic  form,  we  cannot  speak  so  definitely,  and  in  some 
varieties  of  it,  where  it  passes  away  rapidly  and  completely, 
we  may  be  almost  sure  that  no  serious  lesion  exists.  When 
the  paraplegic  j  atient  complains  of  great  pain  in  the  limbs, 
as  well  as  in  the  back,  we  suspect  the  membranes  to  be 
affected  (spinal  meningitis,  whether  primary  or  secondary); 
Avhen  reflex  action  is  abolished  and  faradic  contractility  is 
rapidly  lost,  we  infer  destruction  of  some  part  of  the  cord 
itself,  or  of  the  cells  in  the  anterior  cornua,  or  of  the  motor 
roots  ;  when  reflex  actions  are  greatly  exaggerated,  we  infer 
the  existence  of  a  limited  lesion  in  some  part  of  the  cord 
(see  p.  172).  As  to  etiology,  we  must  inquire  for  any  his- 
tory' of  strain  as  well  as  of  more  obvious  injuries  to  the 
column ;  such  accidents  often  set  up,  in  course  of  time, 
meningitis,  or  disease  of  the  cord  itself.  Caries  of  the  ver- 
tebra; is  a  common  cause  of  paraplegia.  This  may  not 
always  manifest  itself  by  distortion  of  the  spine,  even  in 
cases  which  have  gone  on  to  the  formation  of  psoas  abscess. 
The  influence  of  sexual  excesses,  in  married  life  as  well  as 
otherwise,  accounts  for  various  form's  of  paraplegia  proper, 
as  well  as  locomotor  ataxy.  Sexual  desire  may  be  either 
diminished  or  increased  in  cases  of  disease  of  the  cord  (com- 
1  are  Chapter  xiv.);  impotence,  like  want  of  control  over  the 
rectum  and  bladder,  is  a  common  result  of  paralytic  affec- 
tions. Syphilitic  lesions  of  the  cord  must  be  judged  of  on 
the  same  principles  as  those  of  the  brain. 

Infantile  Paralysis  is  no  doubt  essentially  a  spinal  para- 
lysis, the  lesion,  however,  involves  the  anterior  cornua  alone 
or  chiefly ;  this  localization  accounts  for  the  affection  being 
almost  invariably  purely  motor  in  character,  for  the  great 
trophic  changes,  and  for  the  limitation  of  the  paralysis  in 
many  of  the  cases  to  one  leg  only  or  one  arm.  Not  unfre- 
quently.  indeed,  two  or  more  limbs,  or  even  the  whole  four 


WASTING    PALSY  —  LEAD    PARALYSIS.  183 

limbs,  may  be  uttncked  during  the  early  period,  tlie  illness 
being  characterized  by  pain  and  febrile  disturbance  ;  but  the 
paralysis  Ix^comes,  as  a  rule,  more  limited  and  frequently 
settles  down  to  one  limb,  or  to  one  group  of  muscles.  The 
rapid  loss  of  the  faradic  contractility  of  the  muscles,  and 
their  response  to  weak  currents  from  a  constant  battery  for 
a  considerable  time,  are  points  of  diagnostic  value.  An 
essentially  similar  form  of  paralysis  occurs  sometimes,  but 
only  rarely,  in  the  adult  from  a  similar  lesion  (Amyotrophic 
paralysis). 

In  Wasting  Palsy  the  muscles  may  be,  and  usually  are, 
affected  bilaterally,  but  one  side  is  often  in  advance  of  the 
other ;  the  muscles  of  the  thumb  and  hand,  the  muscles  of 
the  feet,  and  the  deltoids  are  amongst  those  most  frequently 
affected  in  the  ea,rly  stage,  but  nearly  every  group,  including 
the  respiratory  series,  may  ultimately  become  involved.  The 
muscles  usually  respond  to  faradic  electricity  pretty  well,  con- 
sidering their  loss  in  bulk. 

Paralysis  of  the  Extensors  of  the  forearms,  and  more 
rarely  of  the  legs,  is  frequently  found  in  lead  poisoning,  the 
other  muscles  being  intact,  and  sensation  unaffected.  Trau- 
matic paralysis  from  injury  to  the  musculo-spiral  nerve  may 
simulate  this ;  the  history  leaves  no  doubt  in  such  cases  ; 
but  in  those  forms  supposed  to  be  due  to  lying  on  the  arm  or 
to  exposure  to  cold  (so-called  rheumatic),  there  may  be,  in 
patients  exposed  to  lead,  a  certain  difficulty.  The  immunity 
of  the  supinator  longus  in  lead  paralysis  is  important ;  it  is 
tested  by  getting  the  patient  to.  put  his  forearm  in  a  position 
of  half-flexion  and  half-pronation,  and  while  he  tries  to  re- 
tain it  in  this  attitude,  the  observer  proceeds  to  extend  it ;  if 
the  supinator  longus  be  active  it  can  be  seen  resisting  this 
extension  (Duchenne).  The  diminution  or  abolition  of  the 
fiaradic  contractility  of  the  muscles  in  lead  paralysis  is  an 
important  fact,  as  it  is  almost  always  preserved  in  rheumatic 
affections  of  recent  origin.  The  presence  of  a  blue  line  on 
the  gums,  the  history  of  colic,  and  the  occupation  or  sur- 
roundings of  the  patient  are  points  to  be  scrutinized. 

In  unsteadiness  in  walking  we  must  subject  the  patients 
to  the  tests  enumerated  in  the  section  on  this  subject  (see 
pp.  172-174);  and  we  must  direct  our  attention  to  tlieir 
power  of  speaking  distinctly,  to  the  presence  of  any  of  the 
delusions  characteristic  of  general  paralysis,  and  to  any  his- 
tory of  insanity  in  the  family.      (See  Chapter  viii.) 

Affections  of  speech,  deglutition,  &c.,  ara  specially  dealt 


184  DISORDERS    OF    NERVOUS    SYSTEM. 

with  in  the  sections  on  aphasia,  and  paralysis  of  the  ninth 
nerve.  (See  pp.  174—177  and  165).  For  paralysis  of  the 
faoial  and  ocular  muscles,  see  pp.  1G2,  163  and  130—135. 

NEURALGIA. 

Neuralgia,  pain  in  a  nerve,  requires  to  be  considered  as  to 
the  exact  nerves  or  branches  concerned ;  the  whole  of  a 
plexus  of  nerves,  the  brachial  or  sacral  especially,  may  be 
involved.  The  point  of  chief  importance  in  considering  neu- 
ralgia is  to  see  to  avoid  labelling  a  pain  as  neuralgic  when 
there  is  some  other  very  definite  disease  merely  involving  the 
nerve  in  a  secondary  manner.  In  neuralgia  there  is,  as  a 
rule,  little  or  no  fever  ;  the  pain  follows  the  course  of  certain 
nerves  in  a  definite  manner ;  it  is  usually,  if  not  always, 
distinctly  intermittent,  disappearing  completely  at  times ; 
there  are  often  special  tender  spots  corresponding  to  the 
points  where  the  nerve  is  su]3erficial  or  passes  through  open- 
ings in  the  bones  or  fascia ;  there  is  no  inflammation,  tumor, 
or  other  disease  present  to  account  for  the  pain  ;  and  fur- 
ther, certain  nerves  have  a  special  predisposition  to  such 
painful  affections.  The  fifth  nerve,  the  sciatic  nerve,  the 
intercostal  nerves,  and  the  brachial,  lumbar,  and  sacral 
plexuses  are  those  commonly  involved.  Although  the  ab- 
sence of  any  obvious  cause  for  tlie  pain  is  an  important  diag- 
nostic point,  it  is  quite  possible  that  a  true  neuralgia  may  be 
set  up  by  the  irritation,  for  example,  of  a  decaying  tooth,  of 
a  wounded  nerve,  of  prolonged  pressure,  of  an  irritating 
scar,  &c.  Apart  from  these,  which  may  set  up  Avhat  seems 
to  be  a  true  neuralgia,  we  may  have  pains  of  a  reflex  cha- 
racter ;  in  cases  of  irritation  of  the  stomach,  bowels,  ureter, 
nterus,  &c.,  we  often  have  pains  in  the  head  and  limbs, 
which  disajipear  when  the  irritation  passes  off*.  The  pain 
caused  by  a  neuroma  or  a  neuritis  may  here  be  mentioned ; 
there  is  usually  very  marked  local  tenderness  in  such  cases. 

In  addition  to  local  causes,  we  must  have  regard  to  the 
general  condition,  as  this  is  very  important  in  neiu-algia. 
Anai^mia  in  particular  is  very  often  responsible  for  this  aflfec- 
tion,  and  various  debilitating  agencies  likewise  lead  up  to 
it.  Ague  is  said  to  be  an  occasional  cause  of  supraorbital 
neuralgia.  The  hysterical  tendency  frequently  manifests 
itself  as  a  neuralgia  in  various  parts,  sometimes  of  a  fixed, 
sometimes  of  a  shifting  character.  Rheumatism  may  affect 
the  trunk  or  the  sheath  of  a  nerve,  and   so  give  rise  to  a 


FITS.  185 

rheumatic  neuralgia.  Syj^hilis  may  operate  in  a^  similar 
wav,  or  it  may  simulate  neuralgia  from  the  eifects  of  syphi- 
litic tumors  in  the  brain  or  spinal  cord.  Sciatica  is  some- 
times seen  in  the  course  of  gonorrhceal  rheumatism. 

The  gi-eatest  care  is  required  in  the  diagnosis  of  neuralgia, 
as  numerous  blunders  are  committed  in  ascribing  pains  to 
neuralgia  and  rheumatism  which  are  of  quite  a  ditfereiit 
character.  Lumbago,  especially  in  its  slighter  forms,  must 
be  accepted  as  merely  a  provisional  diagnosis  ti  1  the  kid- 
neys, the  urine,  and  perhaps  the  uterus  have  been  examined. 
Pains  in  the  i'ront  of  the  thigh  or  along  the  sciatic  nerve, 
and  neuralgic  pains  in  the  arms  and  legs,  generally,  may 
really  be  due  to  serious  disease  of  the  spinal  column,  the 
cord,  or  its  membranes,  or  to  abscess,  aneurism,  and  malig- 
nant tumors  in  the  abdomen  or  thorax ;  intercostal  neuralgia 
can  seldom  be  safely  affirmed  without  a  careful  examination 
of  the  heart  and  lungs,  and  even  an  apparent  neuralgia  of 
the  fifth  nerve  may  prove  to  be  due  to  cerebral  tumor  or 
incipient  meningitis.  The  influence  of  neuralgia  on  the 
bloodvessels  and  nutrition  is  sometimes  apparent  in  the  con- 
gested state  of  the  affected  part,  in  lachrymation  and  dis- 
charge from  the  nose,  and  in  the  change  of  color  produced 
in  the  hair  near  the  affected  part. 

For  some  points  in  connection  with  paralysis  and  neural- 
gia, see  p.  169  ;  of  anaesthesia  and  neuralsria,  see  pp.  150, 
160,  168. 

FITS  OF  VARIOUS  KIXDS. 

The  nature  of  the  seizures  commonly  called  "Fits"  varies 
so  much,  and  their  character  is  often  so  obscure,  especially 
to  the  inexperienced,  that  a  somewhat  more  general  view  of 
such  attacks  will  be  given  here  than  is  usual  in  systematic 
descriptions.  This  is  the  more  necessary,  as  the  student  has 
frequently  to  discover  from  the  description  given  by  the  pa- 
tient, or  his  friends,  the  true  nature  of  a  so-called  "  fit" 
before  he  can  estimate  its  significance  in  the  previous 
history. 

TS'e  have  then  to  remember,  amongst  the  possibilities — 
Fainting  fits;  fits  of  dyspnoea,  associated,  perhaps,  with 
angina  pectoris,  or  other  forms  of  cardiac  anguisli  and 
thoracic  pain  (see  Dyspnoea,  Chapter  ix.) ;  fits  with  convul- 
sive twitchings  of  the  face  or  limbs,  general,  unilateral,  or 
local,  with  or  without  unconsciousness  ;  fits  associated  with 

16* 


186  DISORDERS    OF    NERVOUS    SYSTEM. 

faralysie,  especially  hemiplegia,  with  or  without  loss  of  con- 
sciousness ;  fits  with  lividity  of  the  face,  unconsciousness, 
and  stertorous  breathing ;  fits  with  simple  unconsciousness, 
without  paralysis  or  convulsion  ;  fits  without  absolute  loss  of 
consciousness,  but  with  agitation,  screaming,  crying,  sobbing, 
laughing,  and  occasionally  with  an  approach  to  convulsions 
or  to  coma ;  fits  with  plastic  rigidity  of  the  limbs,  which  are 
retained  in  the  positions  in  which  they  are  placed,  usually 
associated  with  some  alteration  of  the  consciousness  ;  fits 
with  tonic  spasm  of  the  jaw,  or  of  the  muscles  of  the  trunk 
and  limbs ;  fits  with  inversion  of  the  hands  and  feet  as  a 
princifal  part  of  a  transient  convulsion,  or  persisting  in  a 
comparatively  uncomplicated  manner  for  hours  and  days. 
In  addition  to  these,  attacks  of  giddiness,  or  speechlessness, 
of  cramp  in  the  legs,  of  laryngeal  obstruction  or  "crowing," 
and  many  others,  are  sometimes  spoken  of  as  "  fits,"  but  are 
usually  qualified  as  to  their  nature  by  the  patients  them- 
selves. Some  of  these  need  only  be  named,  as  their  nature 
becomes  apparent  when  a  little  attention  is  directed  to  them, 
either  by  questioning  or  observation.  Some  of  them,  indeed, 
chiefiy  demand  attention  because  of  their  occurrence  under 
peculiar  cii-cumsfances,  simulating  those  fits  of  a  nervous 
nature  with  which  we  are  chiefly  concerned  here.  Thus  a 
severe  attack  of  thoracic  pain  or  cardiac  anguish  may  lead 
to  much  tossing  about,  with  inability  to  speak,  and  may 
ultimately  induce  lainting  and  unconsciousness,  so  that  we 
may  be  led  to  think  of  some  convulsive  disorder  from  cerebral 
causes. 

With  regard  io  fainting  fits,  we  inquire  as  to  the  presence 
of  any  of  the  common  causes  w^hich  induce  such  attacks, 
nervous  shocks,  arising  from  fear,  grief,  excitement,  or  pain; 
the  sight  of  blood,  tlie  loss  of  blood,  the  want  of  food  and 
rest,  especially  with  prolonged  anxiety;  exposure  to  the 
close  atmosphere  of  crowded  rooms  ;  the  existence  of  preg- 
nancy, &c.  Certain  persons,  moreover,  are  known  to  be 
much  more  prone  to  faint  than  others.  In  fainting  fits  the 
patient  has  usually  some  warning  of  the  attack,  and  the  ob- 
servers may  notice  a  preliminary  pallor,  or  sighing,  or  yawn- 
ing ;  even  when  these  are  not  present  in  a  pronounced  form, 
the  patient  has  often  a  sense  of  SAvimming,  or  of  faintness, 
&c.,  so  that  in  the  event  of  his  failing,  he  is  to  some  extent 
saved  by  those  instinctive  movements  of  self-preser\'ation 
which  partial  consciousness  permits  ;  the  element  of  sudden- 
ness often  serves  to  indicate  the  epileptic  fit,  even  when  it  is 


CONVULSION    FITS.  187 

SO  slight  as  to  be  otherwise  liable  to  misinterpretation.  The 
combination  of  hysterical  tendencies  in  their  less  pronounced 
forms,  with  fainting  fits  or  swoons,  may  give  rise  to  consider- 
able confusion.  In  a  simple  fainting  tit  the  pulse  is  feeble, 
the  respiration  quiet,  and  consciousness  abolished,  but  not 
usually  so  absolutely  as  in  cases  of  coma.  No  twitchings 
occur  except,  perhaps,  as  the  patient  wakes  up,  and  no 
paralysis  precedes  or  ibllows  the  fit. 

Convulsion  Jits  are  usually  obvious  enough,  and  can 
scarcely  escape  recognition  when  the  whole  phenomena  are 
before  us  ;  the  difficulties  arise  from  our  sometimes  only  see- 
ing the  latter  part  of  an  attack,  or  from  the  convulsive  part 
being  so  slight  as  not  to  attract  attention.  In  epilepsy,  which 
furnishes  the  type  of  such  fits,  we  have  usually  a  premoni- 
tory sensation,  vision,  or  internal  feeling  of  some  kind  (aura)  ; 
a  sudden  pallor  of  the  face  ;  a  scream  ;  complete  unconscious- 
ness ;  a  sudden  fall,  so  that  the  patient  often  hurts  himself; 
a  series  of  convulsive  movements,  aflecting  the  eyes,  face, 
head,  neck,  trunk,  and  limbs  in  the  general  convulsion  ; 
sometimes  the  convulsion  is  unilateral,  either  throughout  or 
at  the  beginning  of  the  attack,  sometimes  the  convulsion  is 
limited  to  a  single  limb,  or  to  the  facial  muscles  on  one  side  ; 
when  the  convulsion  is  severe  and  general,  the  face  becomes 
blue  from  the  respiratory  muscles  being  involved  ;  the  patient 
frequently  foams  at  the  mouth,  and  the  froth  is  often  bloody 
from  the  tongue  having  been  bitten  in  the  convulsive  move- 
ments of  the  tongue  and  jaws ;  the  convulsion  consists  of  a 
series  of  rapid  muscular  contractions  (clonic),  although  cer- 
tain groups  of  muscles  may  remain  for  a  time  firmly  con- 
tracted and  rigid  (tonic)  ;  the  whole  body  may  be  wriggled 
about  in  the  violence  of  the  convulsion.  After  a  few  min- 
utes, in  ordinary  epileptic  attacks,  the  convulsions  cease,  the 
lividity  begins  to  disappear,  a  period  of  deep  unconsciousness 
with  stertorous  bveathing  supervenes,  and  this  merges 
gradually  into  a  quiet  sleep,  which  may  be  prolonged  for 
some  time  even  after  a  short  interval  of  restored  conscious- 
ness. After  the  fit  the  patient  seems  well,  although  perhaps 
complaining  of  a  headache,  and  of  a  feeling  of  confusion. 
There  is  no  paralysis,  or  if  there  be  hemiplegia  it  is  usually 
very  slight  and  quite  transient  (epileptic  hemiplegia).  After 
the  fit  there  is  sometimes  great  excitement,  and  very  erratic 
conduct  with  or  without  violence,  and  there  may  be  tlie  exe- 
cution of  elaborate  automatic  actions  simulating  a  delibei-ate 


188  DISORDERS    OF    NERVOUS    SYSTEM. 

purpose,  although  quite  apart  from  the  controlling  conscious- 
ness of"  the  individual. 

Such  are  the  features  of  the  typical  epileptic  fit  (grand 
mal)  ;  when  convulsive  attacks,  from  any  cause,  approxi- 
mate to  this  type  they  are  called  "  epileptiform"  ;  but  nearly 
every  one  of  the  individual  i'eatures  enumerated  may  be  ab- 
sent, or  at  least  so  slight  as  to  escape  notice.  In  particular, 
there  may  be  no  obvious  convulsions,  a  sudden  pallor  and 
loss  of  consciousness  being  all  (petit  mal).  Allied  to  this 
are  the  so-called  "  inv^'ard  fits"  of  infants,  in  Avhich  we  have 
'  turning  up  of  the  eyes,  with  apparent  unconsciousness,  and  a 
momentary  rigidity  in  certain  cases.  There  may,  on  the 
other  hand,  be  preservation  of  consciousness,  along  with 
unilateral  or  localized  convulsions  ;  further,  the  convulsive 
part  of  the  attack  may  be  over  before  the  patient  comes 
under  notice,  so  that  tlie  condition  observed  resembles  simple 
coma,  especially  if  there  be  no  evidence  of  struggling,  dis- 
ordered bed-clothes,  wetting  of  the  bed,  bloody  foam,  &c. 
The  existence  of  injury  from  a  fall  occurring  in  connection 
with  a  fit  rather  favors  the  idea  of  an  epileptic  attack  or 
convulsion  fit  of  some  kind,  as  unconsciousness  is  seldom  so 
suddenly  lost  in  other  fits  as  to  prevent  some  effort  at  preser- 
vation. In  apoplectic  attacks  convulsions  occasionally  super- 
vene, and  in  hysteria  the  discrimination  of  it  from  epilepsy 
is  sometimes  impossible ;  indeed  a  complex  condition  of 
liysteroepilepsy  is  recognized  by  some  (notably  of  late  by 
Charcot). 

The  presence  or  absence  of  the  various  featui-es  referred  to 
as  characterizing  a  typical  attack  must  be  noted.  If  possible, 
we  should  notice  or  ascertain  how  the  convulsion  begins, 
whether  with  rotation  of  the  head  to  the  shoulder  and  con- 
jugate deviation  of  the  eyes,  with  nystagmus,  with  twitchings 
of  tlie  lips,  or  with  convulsion  of  the  fingers,  feet,  &c.  Oc- 
casionally tlie  convulsion  is  limited  to  one  side,  or  even  to 
one  part ;  in  such  cases  we  must  make  sure  which  side  is 
affected,  and  if  consciousness  be  not  lost  we  may  learn  from 
the  patient  something  of  his  sensations  in  the  affected  part, 
where  they  began  and  how  they  extended.  In  cases  with 
unilateral  convulsions  we  must  try  to  ascertain  whether  there 
was  paralysis  of  the  affected  side  before  the  fits,  or  whether 
it  appeared  after  the  convulsion,  whether  it  was  transient  or 
M-hether  it  persisted  for  some  time.  When  unconsciousness 
is  not  present  at  the  very  beginning  of  a  fit,  it  is  important 
to  discover  the  time  at  which  it  appeared,  especially  in  con- 


EriLEPTIFORM    FITS.  189 

nection  with  advancing  convulsions  or  sensations  spreading 
up  the  limbs.  It  is  not  always  easy  to  be  sure  of  the  preser- 
vation of  consciousness  in  a  fit ;  we  must  trust  to  the  appeai'- 
ance  of  intelligence  of  the  patient  when  we  speak  to  him,  and 
to  his  power  of  afterwards  describing  what  happened  during 
the  fit,  who  assisted  him,  &c. 

If  the  fits  recur,  we  should  estimate  not  only  their  dura- 
tion but  also  the  length  of  the  intervals  ;  we  should  likewise 
notice  whether  the  muscles  become  quite  relaxed  during  the 
intermissions,  or  whether  there  remains  some  tonic  spasm  ; 
any  appearance  of  an  exciting  cause  must  be  noted  in  these 
recurrences. 

In  connection  with  such  convulsion  fits  we  must  ascertain 
whether  the  patient  has  had  any  attacks  before,  and  at  what 
age  they  began  ;  epile[)sy  in  its  ordinary  form  usually  mani- 
fests itself  in  childhood,  or  appears  about  j^uberty.  Any  his- 
tory or  evidence  of  cerebral  disease  must  likewise  be  searched 
for  ;  particularly  chronic  hydrocephalus,  cerebral  tumors, 
abscesses,  &c.  In  children  we  must  remember  that  various 
forms  of  apparently  slight  irritation  may  cause  convulsions  ; 
disorders  of  tlie  stomach  from  improper  food,  and  diarrhoea 
are  frequent  causes  of  convulsions.  In  the  atrophic  and 
aniemic  condition  resulting  from  these  or  similar  causes,  we 
may  have  convulsions  and  other  symptoms  simulating  to  some 
extent  the  course  of  meningitis ;  but  the  history,  the  diar- 
rhoea and  the  collapsed  fontanelle  serve  to  guide  the  diagno- 
sis of  this  spurious  hydrocephalus  (hydrocephaloid).  The 
irritation  of  the  gums  and  mouth  during  the  period  of  denti- 
tion, the  presence  of  worms  in  the  intestines,  and  indeed  any 
thing  which  is  apt  to  produce  pain  and  feverishness,  may 
give  rise,  in  predisposed  subjects,  to  general  convulsions. 
Children  with  rickets  and  laryngismus  stridulus  are  fre- 
quently subject  to  general  convulsions.  Acute  illnesses 
(fevers,  inflammations  of  the  lungs,  and  meningitis)  some- 
times begin,  especially  in  children,  with  a  fit  of  this  kind, 
and  whooping  cough  is  particularly  apt  to  be  thus  complica- 
ted in  its  course ;  in  hydrocephalus  acutus,  convulsions  com- 
monly supervene  at  some  stage  of  the  illness.  In  the  course 
of  scarlatina,  convulsions  may  be  due  to  the  supervention  of 
renal  disease.  Various  loisojis  are  well  known  to  give  rise 
to  convulsions.  In  adults,  when  there  is  no  history  of  typical 
epilepsy,  we  must  consider  whether  the  fits  may  be  due  to  in- 
temperance and  chronic  alcoholism,  or  to  syphilis  or  to  Bright's 
disease.     A  sudden  outburst  of  convulsions  mav  be  the  form 


190  DISORDERS    OF    NERVOUS    SYSTEM. 

in  which  patients  so  affected  may  first  be  laid  aside.  Other 
forms  of  cerebral  tumor,  as  well  as  the  syphilitic,  may,  how- 
ever, declare  themselves  in  this  way.  Renal  disease  may 
likewise  surprise  a  patient  thus  who  has  scarcely  ever  re- 
garded himself  as  ill ;  but  usually  there  has  been  some  history 
of  dropsy,  of  recent  scarlatina,  or  some  indication  of  serious 
disease.  The  urinary  examination  is  important  in  such 
cases  ;  but  we  must  remember  that  convulsion  fits  from  any 
cause,  are  often  associated  with  temporary  albuminuria ;  the 
microscopic  examination,  by  revealing  fatty  casts  and  epi- 
thelium, may  here  guide  us  in  recognizing  a  chronic  form  of 
the  disease. 

Cerebral  embolism  and  thrombosis,  certain  forms  of  apo- 
plexy, and  senile  degenerative  changes  in  the  brain,  some- 
times reveal  themselves  by  convulsions. 

In  women  during  pregnancy  and  the  puerperal  state  we 
are  apt  to  have  convulsions,  .depending  apparently  on  irrita- 
tion, from  distension  or  otherwise,  of  the  uterus,  and  on  the 
presence  of  albumen  in  the  urine  with  all  that  this  signifies. 
Other  forms  of  irritation  propagated  from  the  sexual  organs 
may  likewise  be  mentioned,  as  causing  convulsions ;  and  in 
particular  the  premature  or  unnatural  excitement  produced 
by  masturbation ;  ordinary  sexual  intercourse  may  deter- 
mine the  occurrence  of  a  fit  in  those  predisposed  to  such 
attacks. 

Hysterical  Fits  assume  such  a  variety  of  forms  that  the 
leading  features,  or  rather  the  commoner  ones,  only  can  be 
noticed.  As  a  rule,  consciousness  is  not  abolished,  although 
there  may  be  changes  in  this  respect,  and  unconsciousness 
may  be  simulated;  occasionally,  indeed,  consciousness  may 
seem  to  be  really  suppressed.  This  test,  therefore,  although 
important,  is  by  no  means  absolute;  on  the  other  hand,  the 
preservation  of  consciousness  in  unusual  forms  of  epilepsy 
must  also  be  remembered.  The  emotional  disturbance  in 
hysteria  is  perhaps  the  most  im|)ortant  feature;  it  is  practi- 
cally confined  to  the  female  sex ;  the  rising  of  a  ball  in  the 
throat  (globus),  sobbing,  sighing,  laughing,  crying,  and  even 
screaming  are  quite  common.  Along  with  these  manifesta- 
tions there  may  be  tossing  about  and  great  agitation,  so  that 
the  movements  may  bear  a  superficial  resemblance  to  those 
of  epileptic  convulsions,  but  we  can  usually  detect  that  they 
are  to  some  extent  under  the  control  of  the  will  if  the  patient 
is  dealt  with  firmly. 

In  other  cases  the  movements  only  amount  to  a  general 


LOCAL    CONVULSIONS.  191 

shaking  of  the  body  or  limbs,  or  to  quivering  of  the  facial 
muscles  when  the  patient  is  doing  her  best  to  control  h-erself. 
Swoonings  and  brief  periods  of  simple  unconsciousness  con- 
stitute at  times  the  only  manifestations  of  hysteria. 

The  determining  causes  of  such  seizures  often  supply  im- 
portant information ;  quarrels,  disappointments  in  love,  ex- 
citement, vexation,  &c.,  may  be  named  as  among  the  more 
obvious  of  these.  Disturbance  of  the  sexual  organs  and 
functions  (disordered  menstruation,  amenorrhoea,  change  of 
life,  &c.)  are  likewise  important.  In  debility  from  long- 
continued  and  exhausting  diseases  hystei-ical  tendencies  may 
show  themselves  in  patients  who  had  hitherto  been  able  to 
control  such  manifestations,  so  tliat  these  attacks  may  form 
one  of  tlie  features  of  grave  disease  or  of  impending  death. 

Plastic  Rigidity,  as  found  in  catalepsy,  is  closely  allied  to 
hysterical  fits;  in  a  sliglit  form  it  may,  indeed,  be  noticed 
occasionally  during  sucli  seizures.  In  its  most  typical  mani- 
festations the  limbs  and  also  the  neck  and  trunk  may  be 
retained  even  in  the  most  unnatural  positions  in  which  they 
are  placed,  or  in  which  they  may  liappen  to  be  when  the  fit 
occurs.  The  arms,  for  example,  may  be  moulded  into  va- 
rious attitudes,  and  retained  in  positions  not  easily  maintained 
by  a  muscular  man,  or  the  head  may  be  bent  back  and  fixed 
in  such  a  position  that  the  patient  remains  resting  on  the 
back  of  her  head  with  the  body  arched,  as  occurs  in  certain 
cases  of  tetanus.  Such  a  fit  may  last  for  a  considerable 
time,  or  there  may  be  a  succession  of  such  fits,  with  intervals 
of  a  natural  condition.  In  grave  forms  of  such  seizures  the 
consciousness  is  obviously  involved,  but  in  slighter  cases  it 
is  preserved.  Like  hysteria,  catalepsy  may  be  said  to  be 
almost  confined  to  the  female  sex. 

Local  Convulsions  have  already  been  referred  to  as 
sometimes  replacing  general  convulsions  in  an  epileptic  fit 
("  Jacksonian  Epilepsy"),  but  the  spasms  which  affect  the 
hands  and  feet  of  children  must  be  specially  mentioned 
(^carpo-pedal  spasms).  The  hands  and  feet  are  bent  in  and 
slightly  flexed,  and  the  thumbs  are  dra-WTl -^'CroF.fi'.  tba-ptLlm^^ 
This  form  of  spasm  is  common  in  infantile  convulsions  from 
any  cause;  it  sometimes  precedes  general  convulsions,  the 
spasm  coming  or  going  frequently,  or  being  preserved  con- 
tinuously for  some  time  before  the  general  attack  comes  on. 
In  more  favorable  cases  the  nervous  affection  may  never  get 
any  further  than  this  local  spasm.  This  affection  is  often 
associated  with  a  swollen  appearance  of  the  dorsum  of  the 


192  DISORDERS    OF    NERVOUS    SYSTEM. 

ieet  and  lisinds,  arising  in  cases  of  protracted  infantile  diar- 
rhoea. This  s]msm*niay  likewise  linger  between  successive 
attacks  of  general  convulsions,  or  it  may  continue  for  a  con- 
siderable time  after  a  single  fit,  without  any  repetition. 
Along  with  tliis  carpo-pedal  spasm  there  may  be  some  tonic 
contraction  of  the  muscles  of  the  back  and  of  the  nape  of  the 
neck.      Consciousness  is  not  usually  lost  in  this  condition. 

This  state  is  closely  connected  with  the  occurrence  of  gene- 
ral convulsions,  of  which  it  is  to  be  regarded  as  a  warning ; 
but  a  less  serious  form  of  spasm  in  these  situations  is  de- 
scribed under  the  name  of  Tetany  ;  the  thumbs  are  the  parts 
most  frequently  affected,  but  the  feet  may  also  be  involved  ; 
in  a  more  severe  form  the  muscles  of  the  trunk  and  of  the 
jaw  may  become  affected,  but  the  rigidity  does  not  begin  in 
this  last  named  situation  as  in  tetanus.  Tlie  contraction  is 
not  usually  very  painful,  but  pain  may  be  caused  if  the 
attempt  be  made  to  overcome  the  spasm.  It  usually  varies 
in  intensity  from  time  to  time,  even  when  a  degree  of  it 
remains  persistently  for  days.  It  has  a  special  tendency  to 
recur  after  intervals  of  apjiarently  perfect  recovery.  Al- 
tliough  commonest  in  children  it  affects  adults  occasionally 
especially  women  during  lactation  ;  its  frequency  appears  to 
be  related  to  climatic  influences,  and  it  has  been  su])posed  to 
be  connected  with  rheumatism. 

Spasms  or  Cramjjs  in  the  legs  are  common  in  many  per- 
sons ;  they  often  occur  suddenly  during  the  night,  without 
any  obvious  cause,  but  their  frequent  dependence  on  gastric 
disorders,  acidity,  &c.,  is  quite  certain.  Such  cramps  are 
very  painful  while  they  last.  A  more  general  form  of  the 
same  thing  sometimes  presents  a  resemblance  to  "  Tetany" 
as  just  described.  In  addition  to  gastric  disorder,  we  must 
mention  diarrhoea  and  cholera  as  giving  rise  to  painful 
cramps ;  they  are  also  common  in  connection  with  child- 
birth. Spasms  in  the  limbs  also  occur  as  already  mentioned 
in  connection  with  cerebral  and  spinal  disease  (see  p.  171). 

Local  Sjjasms  in  the  region  of  the  face  and  neck  likewise 
demand  attention.  Such  spasms  may  be  tonic — the  contrac- 
tion of  the  muscle  being  steady  and  sustained — or  they  may 
be  clonic  and  twitching  in  character.  Some  tonic  contrac- 
tion of  certain  facial  muscles  is  found  at  times  in  connection 
with  severe  neuralgia;  the  person's  face  assumes  a  fixed 
appearance,  as  if  he  were  acting  a  part  {histrionic  spasm^. 
Similar  spasms,  usually,  however,  more  limited  to  isolated 
muscles,  sometimes  remain  after  an  attack  of  facial  paralysis. 


CONVULSIVE    ■\VRY-NECK.  193 

Permanent  contraction  of  the  muscles  of  the  neck,  espe- 
cially of  the  sterno-mastoid,  gives  rise  to  a  form  of  lory-neck. 
This  is,  perhaps,  usually  congenital,  and  resembles  club-foot 
so  far.  Occasionally,  however,  it  appears  about  puberty,  or 
even  later,  especially  in  females,  and  is  generally  classified 
then  as  hysterical.  In  such  cases  it  may  persist  for  years. 
Deviations  of  the  head  may  arise  from  rheumatic  aflPections  of 
the  muscles  of  the  neck,  or  from  the  influence  of  cold,  giving 
rise  to  the  common  form  of  "  stiiF  neck"  of  a  passing  charac- 
ter. A  similar  deviation  may  result  from  painful  glandular 
enlargements  in  the  neck.  Caries  of  the  vertebne  may  lead 
to  a  lurching  over  of  the  head  to  one  side,  and  disease  of  the 
occipito-atlantoid,  or  axoidal  articulations,  usually  gives  rise 
to  a  very  peculiar  fixity  of  the  muscles  of  the  neck,  which 
become  affected  in  this  vray  simply  to  preserve  the  patient 
from  the  pain  due  to  the  least  movement  of  the  head. 

Convulsive  movements  or  twitchings  of  the  muscles  of  the 
face  and  neck  are  also  common.  Those  of  the  orbicularis 
palpehrarum  have  already  been  noticed  (see  Eye,  p.  138). 
Convulsive  movements  of  the  facial  muscles  on  one  side  are 
sometimes  obviously  due  to  local  epileptic  seizures  {convul- 
sive tic).  Such  twitchings  are  usually  not  painful,  but  they 
may  be  associated  with  some  painful  affection  of  the  fifth 
nerve. 

Twitching  of  the  sterno-mastoid  on  one  side,  or  more 
rarely  of  the  trapezius,  constitutes  a  most  troublesome  ner- 
vous affection,  which  sometimes  assumes  great  violence  and 
prevents  sleep.  These  movements  are  under  the  influence 
of  the  spinal  accessory  nerve,  as  shown  by  the  effect  (usually 
temporary)  of  its  section,  they  are  obviously  of  centric 
origin,  and  depend  probably  on  disease  at  the  root  of  this 
nerve.  This  convulsive  wry-neck  may  persist  for  years  in  a 
violent  form,  or  it  may  assume  a  troublesome  severity  only 
occasionally. 

Bilateral  convulsion  of  the  muscles  acting  on  the  head  is 
found  in  the  nodding  convulsions  of  children,  which  some- 
times proceed  to  a  bending  of  the  whole  trunk  (eclampsia 
nutans,  salaam  convulsions).  Such  an  affection  may  be 
symptomatic  of  cerebral  tubercle,  although  it  also  occurs  as 
a  more  independent  disease  (see  also  p.  172). 

Tonic   Spasm  affecting  the  jaw  (trismus)  is  usually  the 

earliest  manifestation  of  tetanus  and  of  strychnia  poisoning, 

and  so  must  be  watched  for  Ttliring  tRe  administration  of  this 

medicine.      Tetanus  affects    the    muscles   of  the   back  and 

17 


194  DISORDERS    OF    NERVOUS    SYSTEM. 

abdomen  as  well  as  the  limbs.  TN'hen  the  back  is  affected, 
so  as  to  be  curved  backwards,  the  form  is  named  "  opistho- 
tonos ;"  when  the  abdominal  muscles  are  so  much  involved 
as  to  cause  a  bending  forward,  "  emprosthotonos"  is  tlie 
name  employed ;  "  pleurosthotonos"  is  applied  to  similar 
lateral  deviations.  Tetanus  comes  under  the  notice  of  sur- 
geons in  connection  with  injuries,  but  it  occurs  also  idio- 
pathically,  sometimes  from  exposure  to  cold  and  wet.  The 
distinctions  of  tetanus  from  strychnia  poisoning  must  be 
sought  for  in  detail  in  the  text  books  ;  but  the  tendency  to 
remissions  and  to  exacerbations  brought  about  by  in-itations 
of  various  kinds,  constitutes  one  of  the  features  of  poisoning. 
The  early  affection  of  the  jaw  in  tetanus  and  stryclmia 
poisoning  forms  a  marked  contrast  with  the  late  develop- 
ment of  this  symptom  in  the  severe  forms  of  "  tetany" 
already  alluded  to. 

Spasms  of  deglutition  on  attempting  to  swallow,  form  one 
of  the  features  of  hydrophohia.  Spasmodic  stricture  of  the 
cesophagus  is  rare  but  not  unknown.  Spasms  of  the  glottis 
as  they  occur  in  cases  of  pertussis,  laryngismus  stridulus, 
larvngeal  disease,  and  thoracic  tumor  are  referred  to  in  the 
section  on  dyspnoea,  &c.  (Chapter  ix.). 

Sudden  Paralysis  is  sometimes  spoken  of  as  a  "  fit"  or 
"  stroke."  In  connection  with  the  occurrence  of  this  we 
must  observe,  or  try  to  ascertain,  whether  the  paralysis  came 
on  suddenly  in  its  maximum  extent,  or  in  a  series  of  succes- 
sive invasions,  or  whether  the  advance  was  marked  by  tem- 
porary or  partial  recoveries.  The  exact  manner  in  which 
the  paralysis  occurs  should  be  ascertained,  so  that  we  may 
judge  of  the  rapidity  of  the  attack,  and  of  the  parts  involved, 
and  by  such  inquiries  we  are  often  able  to  ascertain  the 
presence  or  absence  of  consciousness  during  the  seizure. 
Tendencies  to  giddiness,  flashes  of  light,  noises  in  the  ears, 
and  unusual  disposition  to  sleep,  may  be  inquired  about  :  the 
friends  of  a  patient  can  often  give  important  information  on 
these  points  if  the  patient  himself  be  unable  to  do  so.  If 
there  be  unconsciousness  we  should  try  to  ascertain  at  what 
period  it  supervened,  if  it  did  not  form  the  initial  symptom, 
whether  it  ob"s"iously  deepened  or  lightened  after  it  appeared, 
whether  it  was  associated  with  stertorous  breathing,  and 
whether  the  face  was  flushed  or  livid  at  the  beginning  of  the 
fit,  or  on  the  contrary  pale  and  bloodless. 

When  a  patient  is  deeply  unconscious  it  is  not  easy  to  de- 
termine the  presence  of  paralysis :  but  a  certain  twist  in  the 


COMA.  195 

features,  and  a  difference  at  tlie  angles  of  the  mouth,  often 
serve  to  reveal  a  one-sided  paralysis.  On  lifting  or  moving 
the  limbs  we  may  be  able  to  discover  a  distinct  difference  in 
the  flaccidity  of  the  two  sides,  and  we  are  often  able  to  ob- 
serve that  any  restless  movements  of  the  patient  are  confined 
to  the  limbs  of  the  one  side.  Attention  must  be  directed  in 
the  further  examination  to  the  state  of  the  heart  and  blood- 
vessels (rigid  arteries,  hypertrophy  or  valvular  disease  of 
the  heart,  &c.),  to  the  state  of  the  kidneys,  and  to  the  pre- 
vious history  of  any  former  attacks.  The  immediately 
preceding  events  are  also  important,  exposure  to  the  sun,  the 
presence  of  excitement,  the  facts  as  to  eating  and  drinking, 
&c.     (See  section  on  Paralysis,  p.  166.) 

Coma  has  already  been  referred  to  as  a  frequent  accom- 
paniment of  paralysis  and  convulsion.  Unconsciousness 
likewise  occurs  in  simple  fainting  fits,  and  forms  one  of  the 
less  common  manifestations  of  hysterical  attacks,  and  of  the 
rare  conditions  known  as  catalepsy,  mesmeric  trance,  &c. 

But  coma  may  exist  apart  from  such  complications.  As 
explained  under  the  section  on  convulsion  and  sudden  pa- 
ralysis, it  is  not  always  easy  to  say  whether  the  comatose 
state  is  complicated  by  these:  indications  for  the  discrimina- 
tion are  given  under  these  headings,  but  with  regard  to  pa- 
ralysis, we  have  often  to  wait  till  the  coma  passes  away 
before  we  can  judge ;  with  regard  to  convulsions  Ave  may 
remain  in  doubt  unless  there  be  a  repetition  of  them.  More- 
over, in  a  fit,  essentially  of  an  epileptic  character,  the  con- 
vulsive part  may  be  absent,  as  already  remarked. 

Many  diseases  terminate  in  coma  lasting  for  some  time 
before  death,  and  coma  forms  a  frequent  episode  in  febrile 
diseases  which  are  attended  with  delirium.  In  such  cases 
we  have  usually  a  series  of  symptoms  leading  up  to  the 
comatose  condition,  preparing  us,  as  it  were,  for  its  occur- 
rence. 

When  occurring  suddenly,  apart  from  any  manifestations 
of  nervous  disturbance,  or  when  developed  rapidly,  even  in 
the  midst  of  nervous  symptoms,  it  calls  for  consideration 
under  the  present  section.  The  most  striking  form  of  this 
sudden  coma  occurs  in  renal  disease,  the  nervous  complica- 
tion taking  the  form  of  urfemic  coma  instead  of  convulsion. 
It  may  supervene  without  warning,  and  after  lasting  for  a 
variable  period  of  hours  or  days,  it  may  pass  off  suddenly 
and  completely  without  leaving  any  apparent  effects.  We 
must  in  such  cases  test  the  urine  with  care :  it  may  be  worth 


196  DISORDERS    OF    NERVOUS    SYSTEM. 

while  even  to  draw  off  some  -svitli  a  catheter  for  the  purpose. 
We  should  also,  if  possible,  ascertain  to  what  extent  urine 
had  been  passed  for  some  days  before  the  lit — whether  it  was 
deficient  in  quantity  or  quality.  We  inquire  also  for  any 
history  of  dropsy,  or  other  evidence  of  renal  disease,  dimness 
of  vision,  or  the  like.  In  renal  coma  the  pupils  are  usually 
contracted,  or  at  least  not  dilated;  and  the  temperature  is 
not  elevated:  it  may  even  be  low.  The  test  for  ammonia  in 
the  breath,  by  means  of  its  action  on  the  fumes  of  a  drop  or 
two  of  strong  hydrochloric  acid  placed  on  a  glass  rod,  is  not 
very  satisfactory:  adaptations  of  !Nessler's  test  solution  have 
likewise  been  tried,  but  not  with  much  success. 

Very  different  in  most  respects  from  this  is  the  coma 
found  at  the  violent  onset  of  scarlet  fever,  measles,  and  some 
other  specific  fevers.  The  coma  in  sach  cases  attacks  chil- 
dren especially,  after  a  short  period  of  delirium  and  excite- 
ment, in  the  midst  usually  of  pretty  high  fever.  In  such 
cases  the  diagnosis  is  often  enveloped  in  much  obscurity, 
owing  to  the  absence  or  suppression  of  the  rash,  and  the 
true  natm-e  of  the  attack  may  only  appear  on  the  subsequent 
occurrence  of  some  fever  in  other  inmates  of  the  house. 

The  whole  group  of  poisons  classed  as  narcotics  produce 
coma  or  unconsciousness.  Of  these  the  commonest  and  most 
important  is  opium.  This  may  cause  coma  in  certain  cases 
when  administered  even  in  medicinal  doses,  especially  in 
renal  disease.  Extreme  contraction  of  the  [)upils  is  an  im- 
portant indication  of  opium  poisoning,  although  found  in 
other  forms  of  coma  due  to  cerebral  disease.  Chloroform, 
chloral,  and  alcohol  must  also  be  remembered :  the  diagnosis 
of  unconsciousness  from  alcohol  as  distinguished  from  cere- 
bral disease  is  often  difficult:  the  smell  of  the  breath  is  im- 
portant but  sometimes  misleading,  as  those  who  feel  ill  may 
have  resorted  to  the  use  of  spirits  on  that  account  just  before 
the  seizure. 

In  nearly  all  cerebral  diseases  coma  plays  an  important 
part;  it  may  be  associated  with  convulsions  and  paralysis, 
or  it  may  occur  alone.  It  is  often  due  to  pressure  on  the 
brain  from  depressed  fracture  and  from  hemorrhage,  so  that 
in  traumatic  cases  the  coma  comes  on  after  the  injury  in  a 
gradual  manner.  Or  the  pressure  may  arise  from  fluid  in 
the  ventricles,  from  meningitis,  or  from  cerebral  or  men  in 
geal  hemorrhage.  Tumors,  abscesses,  thrombosis,  and  other 
forms  of  disease  in  the  brain  often  give  rise  to  disturbances 


CHOREA.  197 

ina,nifesting  themselves  in   coma  which  may  be  transient, 
although  the  cause  may  be  permanent. 

TWITCHING  OR  CHOREIC  MOVEMENTS. 

Twitching  or  choreic  movements  have  been  mentioned  in 
connection  with  paralysis,  but  they  also  occur  independently. 
The  movements  are  erratic,  and  are  specially  developed  when 
the  patient  attempts  to  perform  definite  actions,  such  as  using 
a  spoon, — the  limbs  refusing  to  obey  accurately  the  impulse 
of  the  will.  Even  while  sitting  quietly  twitchings  in  the 
face  and  limbs  occur,  and  these  are  aggravated  on  attention 
being  directed  to  the  patient.  Grimaces,  from  twitchings  of 
the  moutli  and  eyes,  are  the  commonest  forms  of  the  early 
manifestation  of  this  affection.  A  good  test  in  chorea  con- 
sists in  getting  the  patient  to  hold  out  a  stethoscope  at  arm's 
length  on  the  palm  of  the  hand,  or  to  keep  the  arms  steadily 
at  the  side  while  standing  or  walking,  or  to  keep  the  tongue 
protruded  for  a  little  time.  Speech  and  even  deglutition  are 
affected  in  the  more  serious  forms.  One  side  is  often  much 
more  involved  than  the  other,  and  sometimes  is  affected 
alone  (hemi-chorea).  Complications  with  paralysis  and 
weakness  of  mind  also  occur  (see  pp.  170.  and  177). 

Chorea  is  common  in  children,  especially  in  girls,  but  it. 
also  occurs  about  puberty,  and  during  pregnancy,  but  chiefly 
in  those  previously  affected.  We  must  have  regard  to  the 
general  state  of  the  children,  particularly  as  to  ansemia  and 
constipation.  The  disease  is  to  some  extent  hereditary,  or  at 
least  included  in  a  general  family  tendency  to  rheumatic  and 
cardiac  affections,  which  seem  to  have  some  affinity  Avitli  cho- 
rea. Not  unfrequently  we  find  chorea  following  cardiac  disease 
due  to  rheumatism,  but  occasionally  the  chorea  precedes  the 
rheumatism,  and  it  often  occurs  independently  of  it.  The 
heart  must  be  examined  in  choreic  patients  :  systolic  bruits 
are  not  uncommon,  but  many  of  these  pass  away  and  are  not 
due  to  valvular  disease.  Scarlatina  has  also  a  tendency  to 
develop  chorea.  Many  facts  point  lo  the  pathological  con- 
nection of  chorea  with  cerebral  embolism  and  thrombosis. 
The  determining  cause  is  often  supposed  to  be  some  fright, 
but  this  has  probably  been  much  exaggerated  by  the  public. 
When  high  fever  exists  with  chorea  the  case  assunies  a  more 
serious  aspect  :  sometimes  the  pyrexia  is  due  to  rheumatic 
complications.     Local  forms  of  chorea  are  usually  associated 

17* 


198  DISORDERS    OF     NERVOUS    SYSTEM, 

Avith  1  aralysis,  and  seem  to  belong  to  a  different  form  of  dis- 
ease (see  Local  Spasms,  pp.  192,  193). 

PELIRIUM. 

Delirium  is  always  a  sign  of  nervous  disturbance,  but  it 
may  arise  merely  from  a  general  affection  of  the  whole  econ- 
omy operating  on  the  nervous  system.  In  high  fever,  from 
any  cause,  and  in  long  protracted  febrile  states  with  much 
debility,  delirium  is  extremely  common,  so  that  a  certain 
disturbance  of  this  kind  is  habitual  just  before  the  fatal  ter- 
mination of  an  illness.  The  slighter  forms  of  febrile  delirium 
show  themselves  just  as  the  patient  is  half  asleep,  or  before 
he  is  properly  awake  ;  the  talking  as  if  in  sleep  is  continued 
probably  in  connection  with  the  previous  dreams,  even  when 
the  patient  awakes  so  as  to  speak  to  or  answer  tlie  attendants. 
In  the  slighter  forms  of  this  "  wandering"  or  "  wavering," 
the  patient  catches  himself  up  very  quickly,  and  knows  tliat 
he  has  introduced  the  confusion  of  his  dreams  into  his  con- 
versation. In  deeper  forms  of  delirium  the  patient  fails  to 
recognize  any  error,  and  may  go  on  speaking,  or  contending, 
or  struggling  with  the  attendants,  as  if  they  were  the  ene- 
mies conjured  up  in  his  dreams.  Although  the  patient  fails 
to  recognize  those  around,  a  certain  recognition  may  remain, 
and  may  suggest  resemblances  or  reminiscences  from  an  asso- 
ciation of  ideas  which  we  can  sometimes  trace.  In  yet  deeper 
forms  of  delirium  the  external  world  is  less  recognized,  and  the 
patient  shouts,  screams,  or  sings,  quite  irrespective  of  what 
the  attendants  do  or  say.  In  these  two  last  forms  the  patient 
has  often  a  tendency  to  rise  up  and  get  out  of  bed,  probably 
with  the  notion  of  escaping  from  something  disagreeable. 
Another  form  of  delirium  is  characterized  by  low  muttering 
or  by  the  movement  of  the  lips  without  mvich  sound,  varied 
at  times  by  a  few  louder  words,  but  without,  as  a  rule,  any 
great  excitement  or  disturbance.  Picking  at  the  bed-clothes, 
drawing  out  imaginary  threads,  and  weaving  motions  with 
the  arms  are  not  uncommon  in  this  state.     (Conipare  p.  45.) 

All  these  forms  of  delirium  are  common  in  the  specific 
fevers  and  in  severe  inflammations,  very  specially  in  typhus 
fever  and  severe  scarlatina,  in  inflammation  of  the  lungs, 
and  in  meningitis.  The  influence  of  intemperate  habits,  or 
of  the  habitual  use  of  stimulants,  is  very  potent  in  causing 
or  increasing  the  delirium  of  fevers  and  inflammations,  and 
a  mobile  nervous  system  or  great  mental  activity  likewise 


VERTIGO.  199 

tends  in  the  same  direction.  Some  of  these  forms  of  delirium 
are  found  in  various  forms  of  injury  to  the  skull  and  disease 
of  the  brain,  in  intoxication  from  alcohol  and  chloroform, 
and  in  the  poisoned  state  of  the  system  known  as  uremia. 

Delirium  differing  considerably  from  the  foregoing  is  com- 
mon in  delirium  tremens.  In  this  disease  the  patient  is 
affected  with  delusions  and  illusions,  and  is  often  very  sus- 
picious. He  is  usually  full  of  business  of  some  kind  in  his 
delirium,  driving  horses,  hurrying  off  to  the  station,  &c.,  and 
seems  to  see  various  objects  distinctly,  to  which  he  calls  at- 
tention ;  he  addresses  strangers  as  Avell-known  friends,  with 
whom  he  has  had  appointments,  and  gives  long  accounts  of 
circumstances  and  transactions  which  are  essentially  imagin- 
ary, although  mixed  up  with  actual  facts  and  correct  names. 
Sleeplessness  and  trembling  are  usually  present.  The  illu- 
sions produced  by  certain  medicines,  especially  hyoscyamus, 
may  be  mentioned  here. 

When  delirium  is  mixed  up  witli  unmanageable  conduct 
and  violence,  we  speak  of  it  as  Mania,  or  maniacal  delirium. 
It  may  be  merely  an  exaggeration  of  the  delirium  already 
described  as  symptomatic  of  fevers  or  of  inflammations,  &c., 
but  it  may  arise  apart  from  these  as  one  of  the  forms  of  in- 
sanity. It  appears  likewise,  occasionally,  after  epileptic  fits, 
or  even  in  cases  essentially  of  this  nature,  in  which  no  pro- 
per fit  is  observed  (Epileptic  Mania).  Mania  likewise  ap- 
pears after  child-birth  in  various  forms  (Puerperal  Mania), 
sometimes  with  its  usual  violence,  but  oftener  perhaps  in  the 
form  of  melancholia;  but  even  then  there  is  a  tendency  to 
deeds  of  violence,  not  only  as  regards  the  patient  herself,  but 
more  especially  as  regards  her  infant.  In  its  further  progress 
this  is  apt  to  tend  to  dementia.  (Compai'e  the  sections  on 
Epileptic,  Puerperal  and  other  forms  of  Mania,  &c.,  in 
Chapter  viii.) 

VERTIGO. 

Vertigo,  or  giddiness,  and  a  sense  of  swimming,  or  of  un- 
dulating motion,  must  be  considered  as  to  whether  the  sensa- 
tion is  felt  by  the  person  within  himself,  or  whether  external 
objects  only  seem  to  whirl  or  move.  We  may  try  the  effect 
of  closing  the  eyes  as  a  test  of  this.  Both  forms  may  occur 
separately,  or  they  may  be  combined.  A  further  point  of 
distinction  is  whether  the  person  is  perfectly  conscious  of  the 
fallacious  character  of  his  sensations,  preserving  his  power 


200  DISORDERS    OF    NERVOUS    SYSTEM. 

of  reasoning  correctly,  or  whetlier  with  the  vertigo  his  whole 
mind  becomes  confused.  The  usual  cliaracter  of  the  motions 
experienced  is  that  of  whirling  round  either  slowly  or  quickly ; 
but  sometimes  the  movements  seem  even  more  strange,  arti- 
cles appearing  to  be  piled  up  on  the  top  of  each  other,  or 
even  turned  upside  down.  In  slighter  forms  there  is  only 
the  sense  of  heaving  up  and  down,  as  if  on  board  ship,  or 
on  a  suspension  bridge  which  sways  under  our  feet. 

This  symptom  appears  not  unfrequently  in  connection  with 
slight  derangements  of  the  stomach  and  liver,  and  may  be 
associated  with  other  evidence  of  digestive  disorders.  It 
may  thus  appear  after  alcoholic  excesses  as  well  as  during 
the  stage  of  intoxication.  The  use  of  tobacco  by  those  un- 
accustomed to  it,  or  habitual  excess  in  others,  may  likewise 
occasion  vertigo.  Nervous  excitement  in  many  forms,  anger, 
fear,  and  the  presence  of  unaccustomed  surroundings,  give 
rise  to  sensations  of  this  kind,  when,  as  we  say,  the  person 
does  not  know  "  whether  he  is  on  his  head  or  his  feet." 

A  form  of  Stomachal  Vertigo,  of  great  suddenness  and 
severity,  may  be  recognized  in  certain  cases  where  there  is 
not  much  evidence  of  gastric  disorder,  the  name  being  de- 
rived from  the  obvious  effect  of  treatment  directed  to  this 
organ,  especially  by  the  use  of  alkalies,  tonics,  and  nourish- 
ing diet.  The  vertigo  in  such  cases  is  often  very  violent, 
rendering  progression  quite  impossible,  and  not  prevented 
by  closure  of  the  eyes.  "With  this  there  may  be  associated 
the  idea  of  a  yawning  abyss  at  the  feet,  but  the  patient  is 
usually  able  to  argue  correctly  as  to  these  illusions.  Persons 
who  have  had  such  attacks  are  liable  to  their  repetition. 
(  Vertigo  a  stomacho  Iceso.     Trousseau.) 

Vertigo,  associated  with  deafness  or  noises  in  the  ears, 
forms  a  leading  feature  of  Meniere's  disease,  arising  from 
diseases  of  the  labyrinth  or  semi-circular  canals.  (See  Ear, 
p.  158.) 

Vertigo  from  cerebral  congestion,  or  in  connection  with  an 
impending  apoplectic  attack,  usually  appears  with  pain  in 
the  head,  sickness  or  nausea,  and  other  cerebral  symptoms. 
Such  vertigo  may  be  rendered  worse  by  a  full  meal,  or  by 
dyspeptic  disorders,  so  that  we  must  not  at  once  set  down 
this  symptom  to  the  stomach  on  that  account.  In  a  person 
over  fifty  affected  with  vertigo,  especially  if  somewhat  per- 
sistent, although  not  very  violent,  we  must  be  on  our  guard 
against  apoplectic  attacks,  particularly^  if  numbness  in  one 
side,   or    other   indications    of  brain    disease,   are   likewise 


SLEEPLESSNESS.  201 

present.  Attacks  of  vertigo  in  an  extreme  form  are  often 
present  in  cases  of  cerebral  tumor.  Vertigo  likewise  consti- 
tutes a  "  warning"  in  some  cases  of  epilepsy,  or  may  be  the 
chief  part  of  an  attack  of  the  '"  petit  mal." 

Disturbance  of  the  cerebral  circulation,  indeed,  is  proba- 
bly the  common  cause  of  vertigo,  even  when  this  is  brought 
about  by  reflex  irritation  from  the  stomach.  Such  disturb- 
ances may  also  arise  in  feeble  persons,  or  after  fevers,  &c., 
on  suddenly  raising  the  head.  A  certain  approach  to  this 
vertigo  is  common  on  getting  up  for  the  first  time  after  long 
confinement  to  the  recumbent  posture,  or  on  going  out  to  the 
street.  Vertigo  is  likewise  a  common  incident  in  cases  of 
loss  of  blood  and  in  profuse  diarrhoea,  or  it  may  appear  after 
these,  in  the  event  of  the  patient  rising  or  sitting  up.  Occa- 
sionally vertigo  results  from  an  apparently  opposite  cause, — 
the  stopping  of  habitual  discharges. 

Allied  to  vertigo  from  the  sudden  annemia  due  to  hemor- 
rhage, is  the  giddiness  observed  from  more  chronic  deterior- 
ating causes,  overwork,  deficient  food,  prolonged  lactation, 
menorrhagia,  leucorrhoea,  &c. 

The  onset  of  the  specific  fevers  and  acute  iuflammations  is 
often  characterized  by  vertigo,  and  the  state  of  the  system 
known  as  urtemia  may  likewise  give  rise  to  this  symptom. 

A  form  of  vertigo  which  is  liable  to  be  misinterpreted  is 
that  which  is  due  to  weakness  or  paresis  of  the  ocular  mus- 
cles, occurring  especially  in  persons  with  an  abnormal  state 
of  tlie  refraction  of  their  eyes.  Such  paresis,  which  may 
not  give  rise  to  any  obvious  squint,  is  apt  to  produce  some 
apparent  deviation  of  the  objects  looked  at,  and  gives  rise 
to  erroneous  impressions  from  the  unusual  force  exercised  in 
adjusting  the  eyes.  Vertigo  due  to  such  causes  ceases  when 
the  eyes  are  closed.     (See  p.  lo-i.) 

SLEEP. 

Various  disorders  in  the  patient's  sleep  must  be  inquired 
for  and  noted  wlien  present.  There  may  be  sleeplessness,  or 
undue  tendency  to  sleep,  or  the  sleep  obtained  may  be  dis- 
turbed or  troubled. 

Sleeplessness  may  be  due  to  accidental  disturbances,  such 
as  change  of  residence  and  unusual  surroundings,  or  removal 
to  hospital,  and  the  like.  Again,  it  may  be  due  to  anxiety 
or  unnatural  excitement  and  activity  of  the  mind  before 
withdrawing  to  rest,  and  many  other  similar  disturbances  ; 


202  DISORDERS    OF    NERVOUS    SYSTEM. 

these  opei'ate  much  more  powerfully  on  some  people  than 
others.  Pain  is  a  fruitful  cause  of  want  of  sleep ;  this  pain 
mav  be  connected  with  the  disease  under  which  a  patient 
labors,  or  it  mav  be,  as  it  were,  accidental, — from  an  attack 
of  toothache,  &c.  Dyspnoea  and  orthopnoea  may  interfere 
with  sleep,  owing  to  the  inability  of  tlie  patient  to  lie  down 
or  to  keep  in  one  position.  Patients  with  serious  cardiac 
and  renal  disease  affected  in  this  way  can  only  obtain  brief 
snatches  of  sleep,  and  may  be  seen  nodding  oft"  continually 
into  momentary  slumbers,  as  they  sit  up  or  lean  their  heads 
forward :  it  may  be  added  of  some  of  these  patients  that  as 
they  are  never  properly  asleep,  so  they  are  seldom  thor- 
oughly awake. 

ilighly  febrile  states  are  usually  adverse  to  natural  sleep  : 
this  arises  partly  from  the  attendant  restlessness  and  irrita- 
bility which,  instead  of  getting  less  with  the  approach  of 
night,  tend  rather  to  increase  ;  the  presence  of  sweating,  and 
the  discomfort  associated  with  it  when  profuse,  are  apt  to 
aggravate  such  a  condition.  In  these  cases  the  patient,  worn 
out  with  restless  tossing  about  during  the  night,  may  obtain 
some  sleep  about  four  or  five  in  the  morning,  as  the  daily 
remission  of  the  fever  becomes  established. 

Acute  mania  is  often  preceded  by  a  period  of  sleepless- 
ness, which  leads  up  to  it  and  may  seem  to  determine  its 
occurrence.  High  fever  and  delirium  combined  are  very 
adverse  to  sleep,  and  may  prevent  any  sleep  for  many  suc- 
cessive days  and  nights.  The  diseases  in  which  it  is  most 
marked  are  pneumonia,  typhus,  and  delirium  tremens,  but  it 
occurs  in  a  multitude  of  other  diseases.  Patients  who  are 
intemperate  in  the  use  of  stimulants,  and  those  also  whose 
minds  are  usually  very  actively  employed  either  from  their 
natural  disposition  or  from  the  character  of  their  occupations, 
are  apt  to  suffer  most  in  this  respect. 

vSleeplessness  is  often  an  early  indication  of  an  impending 
attack  of  delirium  tremens  and  one  of  the  most  persistent 
symptoms  during  its  continuance.  Chronic  sleeplessness 
may  sometimes  be  attributed  to  the  abuse  of  alcohol  ;  in 
such  cases  the  person  may  sleep  in  the  early  part  of  the  night, 
remaining  awake  after  two  or  three  in  the  morning.  The 
habitual  use  of  opium,  of  chloroform  inhalations,  and  of 
chloral,  begun  perhaps  to  procure  rest,  is  very  often  responsi- 
ble for  the  persistence  of  an  aggravated  form  of  sleeplessness 
which  large  doses  of  these  drugs  may  be  quite  unable  to 
overcome. 


SOMNOLENCE.  203 

A  somewhat  similar  form  of  sleeplessness,  however,  may 
be  found  in  hysterical  patients  and  others  troubled  with 
"  nervousness"  in  various  forms  quite  apart  from  the  use  of 

such  drugs. 

Disturbance  of  the  sleep  by  a  rapid  succession  of  ideas,  or 
by  a  whirl  of  incongruous  or  disagreeable  visions,  is  frequent 
in  the  slighter  forms  of  delirium,  and  it  also  occurs  some- 
times in  those  whose  brains  are  overtaxed.  Such  sleep  may 
leave  the  person  with  a  feeling  as  if  he  had  been  more  busily 
employed  than  while  awake,  and  does  not  atford  any  sense 
of  rest.  Effects  of  this  kind  are  sometimes  produced  by 
medicinal  doses  of  opium  and  other  sedatives,  especially 
when  administered  in  unsuitable  cases  or  in  too  small  doses. 
Dreams  of  terror  which  overtake  the  patient  whenever  he 
goes  off  to  sleep,  and  from  which  he  awakes  bathed  in  cold 
sweat,  are  common  in  deep-seated  suppurations,  disease  of 
the  bones,  and  other  serious  affections  associated  with  hectic 
fever.  These  dreams  are  sometimes  so  terrible  that  the 
patient  struggles  against  the  approach  of  sleep.  Less  alarm- 
ing or  at  least  less  persistent  forms  of  this  trouble  are  found 
in  "  night  mare,"  produced  usually  by  an  undigested  meal 
taken  shortly  before  sleeping.  Slighter  forms  of  this  dis- 
turbed rest  are  very  common  in  various  dyspeptic  disorders, 
and  also  in  functional  derangements  of  the  liver. 

The  "  night  terrors"  which  cause  children  to  waken  up 
and  scream  in  a  scared  manner,  quite  unconscious  apparently 
of  the  presence  of  their  parents  or  attendants,  depend  proba- 
bly on  the  vividness  of  their  dreams,  which  are  not  dispelled 
by  the  sight  of  well-known  faces. 

Somnambulism  or  Xight  Walking,  in  its  milder  forms,  is 
not  uncommon  in  children  as  a  very  occasional  event,  but  it 
continues  to  occur  frequently  in  some  even  till  adult  life  is 
reached  :  it  is  commoner  in  females  than  in  males,  and  indi- 
cates a  sensitive  or  overwrought  nervous  system. 

Undue  tendency  to  sleep  is  sometimes  met  with,  especially 
in  children,  as  an  early  indication  of  the  action  of  the  spe- 
cific fevers,  scarlatina,  and  enteric  fever  in  particular.  It  is 
an  important  symptom  in  various  head  affections,  in  the  later 
stage  of  meningitis  for  example,  and  in  other  forms  of  dis- 
ease characterized  by  pressure  on  the  brain.  In  adults  with 
a  tendency  to  apoplectic  attacks,  undue  sleepiness  and  an 
invincible  disposition  to  go  to  sleep,  especially  after  meals, 
supply  important  warnings  of  an  impending  attack. 

Great  tendency  to  sleep  is  likewise  a  feature  to  be  watched 


204  DISORDERS    OF    NERVOUS    SYSTEM. 

for  CiirefuUy  in  renal  disease,  as  it  frequently  indicates  the 
approach  of  ura^mic  poisoning,  and  may  be  the  precursor  of 
convulsions  or  other  serious  accidents  :  in  this  condition  small 
doses  of  opium  may  produce  alarming  or  even  fatal  effects. 

A  certain  tendency  to  undue  sleepiness  occurs  in  some 
cases  of  anaemia,  from  various  causes  :  a  form  of  this,  occur- 
ring in  children,  sometimes  simulates  liydrocephalus  (spurious 
hydrocephalus,  hydrencephaloid).  Tliis  form  of  disease  is 
usually  associated  with  diarrha3a;  convulsions  may  supervene 
and  perplex  the  diagnosis  even  more.  The  flattened  fonta- 
nelle,  the  previous  diarrhcea,  and  the  pallid  complexion  are 
important  points  in  the  recognition  of  this  condition. 

HEADACHE. 

In  studying  cases  of  headache  v^^e  must  try  to  separate  all 
merely  superficial  pains,  such  as  the  various  forms  of"  neu- 
ralgia and  toothache,  and  also  the  pains  due  to  rheumatic 
aflfections  of  the  face  or  head,  and  syphilitic  periostitis,  or 
affections  of  the  bones.  Sources  of  pain  of  a  deep-seated 
character  also  exist  in  inflammation  of  the  jaw,  or  of  the 
roots  of  the  teeth,  and  in  inflammations  of  the  tympanum, 
of  the  iris,  of  the  eyeball,  orbit,  &c.  In  the  case  of  those 
able  to  express  their  sensations  we  are  usually  guided  aright 
by  their  description  of  the  locality  of  the  pain,  and  by  ap- 
plying the  test  of  pressure ;  but  when  we  have  not  this 
assistance  we  are  often  at  a  loss  in  cases  of  this  kind. 

Apart  from  these  various  pains,  true  headache  is  found  in 
the  eai'ly  stage  of  many  fevers  and  serious  inflammations  : 
when  delirium  comes  on,  the  headache  disappears.  Head- 
aches also  occur  very  frequently  in  cases  of  digestive  dis- 
order, in  various  nervous  affections,  especially  in  heriiicrania 
or  "  sick  headache,"  in  inflammations,  tumors,  hemorrhages, 
and  other  serious  lesions  of  the  brain  and  its  membranes  ; 
headache  likewise  occurs  from  overwork  and  prolonged 
mental  strain,  or  other  undue  taxing  of  the  brain  under  un- 
favorable conditions  (as  in  the  case  of  children  over-weighted 
with  studies  in  close  school-rooms),  in  the  poisoned  state  of 
the  system  known  as  urtemia,  and  in  anoemia  from  prolonged 
suckling,  leucorrhcca,  or  other  exhausting  disorders.  The 
effect  of  strain  on  the  eyes,  from  errors  in  their  refraction, 
must  likewise  be  remembered  as  a  fruitful  and  potent  cause 
of  headache  (see  p.' 155). 

In  the  investigation  of  headache  the  presence  or  absence 


PAIN    IN    THE    BACK.  205 

of  pyrexia  is  most  important ;  when  this  is  ascertained  to 
be  really  absent  by  means  of  careful  and  repeated  thermo- 
metrical  observations  we  may  separate  at  once  the  group  of 
the  fevers  and  many  of  the  internal  inflammations.  The 
association  of  headache  with  sickness  and  vomiting  is  very 
frequently  observed  in  the  most  diverse  forms  of  the  affec- 
tion, but  a  good  deal  of  information  may  be  obtained  by  a 
careful  scrutiny  of  the  exact  connection  between  the  two  ;  in 
particular,  the  state  of  the  tongue,  the  co-existence  of  nausea 
with  the  vomiting,  and  the  occurrence  of  vomiting  without 
apparent  cause,  must  be  taken  into  consideration.  (See  Dis- 
orders of  the  Digestive  System,  Chapter  xi.) 

The  situation  of  the  headache  on  the  one  side,  or  in  front, 
or  behind  is  likewise  of  diagnostic  value  in  some  cases,  and 
the  disturbance  of  the  organs  of  sense,  or  the  paralysis  of 
certain  cranial  nerves  may  throw  light  on  the  nature  and  site 
of  the  lesion.  The  existence  of  vertigo,  of  noises  in  the  ears, 
and  flashes  of  light,  must  likewise  be  considered.  The  oc- 
currence of  disorders  in  the  cerebral  functions,  of  delirium, 
excitement,  insensibility,  with  or  without  paralysis  or  con- 
vulsions, frequently  points  to  certain  forms  of  cerebral  dis- 
ease. Headache  associated  with  some  of  these  symptoms 
often  occurs  in  renal  disease  :  indeed,  headache  may  form 
the  first  indication  of  impending  nervous  disturbance  in  these 
affections  ;  this  may  or  may  not  be  associated  with  a  notable 
diminution  in  the  secretion  of  the  urine. 

PAIN  IN  THE  BACK. 

This  symptom,  like  headache,  occurs  at  the  beginning  of 
many  of  the  specific  fevers  and  some  of  the  acute  inflamma- 
tions. It  is  very  specially  prominent  in  the  case  of  small- 
pox. In  rheumatic  affections  pain  in  the  back  is  sometimes 
a  very  marked  feature  of  the  complaint,  but  the  other  joints 
also  usually  show  some  indication  of  pain  and  swelling.  In 
disease  of  the  spinal  cord,  and  more  especially  in  spinal 
meningitis,  there  is  often  pain  in  the  back,  although  it  may 
radiate  in  various  directions.  Pressure  over  the  various  ver- 
tebrae, and  the  effect  of  heat  and  cold  to  the  spine,  should 
be  tried  in  such  cases.  The  sense  of  constriction,  as  if  by 
a  cord,  is  likewise  common  in  spinal  diseases.    (See  p.  160.) 

Pain  in  the  lumbar  region  is  often  designated  "  Lumbago ;" 
such  an  affection  may  be  rheumatic,  gouty,  or  neuralgic. 
Many  cases,  however,  carelessly  set  down  as  lumbago,  are 
18 


206  DISORDERS    OP    NERVOUS    SYSTEM. 

often  due  to  much  more  serious  ailments,  especially  to  dis- 
ease of  the  kidney,  renal  calculus,  &c.  Atlections  of  the 
bladder  also  sometimes  give  rise  to  pain  in  this  situation. 
Pain  in  the  lumbar  and  sacral  region  is  a  very  common 
feature  in  inflammations,  flexions,  and  various  affections  of 
the  womb,  or  other  disorders  of  the  female  organs.  (See 
Chapter  xv.) 

Disease  of  the  bones  of  the  spine  (with  or  without  incipi- 
ent abscess)  and  aneurism  of  the  aorta  are  frequent  sources 
of  severe  and  intractable  pain  of  a  most  puzzling  character, 
as  the  pain  may  exist  for  a  long  time  before  definite  evidence 
of  their  presence  can  be  ascertained.  Careful  search,  how- 
ever, should  be  made  for  indications  of  these  diseases,  and 
the  possibility  of  their  presence  must  be  remembered  in 
obscure  cases. 


207 


CHAPTER  YII. 
THE  USE  OF  ELECTRICAL  IXSTRUMEXTS.' 

Electrical  instruments  are  useful  in  diugnosis,  prog- 
nosis, and  treatment.  Tlie  varieties  of  batteries  and  of  gal- 
vanic elements  employed  are  very  numerous,-  but  tv\'o  forms 
of  instruments,  ditfering  essentially  in  respect  of  the  kind  of 
electricity  they  furnish,  must  be  clearly  recognized. 

I.  The  GALyANic  current  is  obtained  from  a  galvanic 
battery  or  voltaic  pile,  consisting  of  a  series  of  plates  or 
cylinders  modified  in  various  Avays.  Each  "element"  in  the 
battery  consists  of  a  "  pair,"  composed  of  dissimilar  mate- 
rials, and  these  are  contained  in  a  cell,  along  with  some  kind 
of  exciting  fluid. 

The  strength  of  the  current  from  the  battery  is  regulated 
by  the  number  of  these  elements  called  into  play,  and  the 

'  In  addition  to  the  works  on  nervous  diseases  referred  to  in  the 
two  last  chapters,  the  following  writers  may  be  referred  to  spe- 
cially :  Altliaus,  Tibbits,  Poore,  Duchenne,  and  Meyer.  Dr. 
M'Call  Anderson's  "  Clinical  Lectures"  may  be  consulted  regard- 
ing the  galvano-puncture  of  aneurism. 

2  Names  of  the  Principal  Elements  used  in  medical  batteries. 
Biinsen^s:  charcoal  and  zinc  plates,  with  water  or  dilute  sulphuric 
acid  in  contact  with  the  zinc,  and  this  separated  by  a  porous 
cylinder  from  strong  nitric  acid  which  surrounds  the  charcoal. 
SloIirer''s  modification  of  Buusen's  :  chromic  acid  is  introduced 
within  the  charcoal  cj'linder,  and  only  one  fluid — dilute  sulphuric 
acid — is  used.  Stohrer's  portable  continuous  current  battery  con- 
sists of  charcoal  and  zinc  plates  in  narrow  glasses  with  dilute  sul- 
phuric acid.  DanielVs:  copper  and  zinc  plates  with  two  fluids, 
separated  by  a  porous  eartlienware  cylinder  ;  a  saturated  solution 
of  sulphate  of  copper  in  dilute  sulphnric  acid  being  in  contact 
with  the  copper  plate,  and  water  or  dilute  sulphuric  acid  with  the 
zinc.  Smee^s:  platinized  silver  plates  and  zinc  plates,  excited  by 
dilute  sulphuric  acid.  Grovels:  platinum  and  zinc  plates,  with 
strong  nitric  acid,  as  described  in  Bunsen's,  in  contact  with  the 
platinum,  and  separated  by  porous  earthenware.  LecIancM :  char- 
coal with  peroxide  of  manganese  in  a  porous  cell  introduced  with 
a  rod  of  zinc  into  a  solution  of  chloride  of  ammonium.  Becker- 
Muirhead  and  Siemens  and  Halshe  elements  are  modifications  of 
Daniell's. 


208  ELECTRICAL    INSTRUMENTS. 

current  is  received  direct  from  these  plates,  througli  wires 
and  handles,  without  the  intervention  of  any  coil  or  magnet. 
This  form  of  electricity  is  called  the  "  Galvanic,"  "  Voltaic," 
or  "  Primary  Battery  current ;"  also  the  "  Continuous  cur- 
rent," or  "  Constant  current."' 

II.  The  Faradic  form  of  electricity  can  be  derived  from 
two  different  sources  :  (1)  from  a  galvanic  battery  or  element, 
as  just  described;  or  (2)  from  the  action  of  a  fixed  magnet, 
usually  made  in  the  horse-shoe  form.  In  both  cases,  how- 
ever, the  intervention  of  a  coil  is  absolutely  essential. 

In  the  first  of  these  two  forms  {Electro-magnetic,  Volta- 
dy7iamic  instruments)  the  current  from  the  cell  is  passed 
through  the  coil,  and  ]:)Owerful  instantaneous  cui'rents  are  in- 
duced in  the  coil  at  the  joining  and  the  breaking  of  the  cir- 
cuit— these  being  alternately  in  opposite  directions.  (Hence 
the  terms  "  interrupted"  and  "induced"  current  for  this  form 
of  electricity.)  The  strength  of  the  current  is  much  inten- 
sified by  the  presence  of  a  piece  of  soft  iron,  or  a  bundle  of 
wires,  placed  within  the  centre  of  the  coil ;  and  the  strength 
of  these  currents  is  usually  regulated  by  the  approximation 
or  removal  of  the  bulk  of  the  coil  to  or  from  this  central 
piece  of  iron  which  is  converted  into  a  magnet  so  long  as  a 
current  is  being  passed  through  the  coil.  Sometimes,  how- 
ever, the  regulation  is  effected  by  means  of  a  copper  cylinder 
which  reduces  the  strength  of  the  current  in  proportion  as  it 
is  made  to  cover  the  coil  or  the  magnet.  A  secondary  coil 
is  arranged  outside  of  the  first,  and  can  be  moved  over  it 
towards  the  central  magnet  or  away  from  it.  Currents  are 
"  induced"  again  in  this  outer  coil  in  opposite  directions  to 
those  in  the  inner. 

In  the  second  form  of  Faradic  electricity  {Magneto- Electric 
instrv,ments),  two  coils  are  arranged,  in  the  form  of  little 
bobbins  which  by  some  mechanical  arrangement  (such  as  the 
turning  of  a  handle)  are  brouglit  alternately  and  in  rapid 
succession  in  front  of  the  two  poles  of  a  horse-shoe  magnet. 
There  are  pieces  of  soft  iron  within  these  bobbin-like  coils, 
and  these  are  magnetized  and  demagnetized  according  as 
they  are  approximated  to  or  removed  from  the  poles  of  the 

'  The  word  constant,  as  applied  to  galvanic  currents,  differs  from 
"  continnons,"  in  imjjlying  not  merely  the  absence  of  interrup- 
tions, but  also  constancy  in  the  strength  of  the  current  for  definite 
although  for  variable  periods.  Daniell's  battery  is  the  only  one 
constant  during  long  operations,  biit  batteries  which  are  tolerably 
constant  for  periods  of  an  hour  or  two  meet  most  of  the  medical 
requirements  in  this  respect. 


THERMIC    AND    CHEMIZAL    EFrECTS.  209 

magnet  :  currents  similar  to  those  described  ra  the  preceding 
paragraph  are  developed  at  each  act  of  magnetizing  and 
demagnetizing. 

Both  of  these  forms  (electro-magnetic  and  magneto-elec- 
tric) are  to  be  regarded,  for  most  medical  purposes  at  least, 
as  essentially  similar ;  they  are  both  spoken  of  as  ••  Faradic." 
"  induced,"  and  •'  interrupted"  currents.  These  currents  are 
instantaneous  and  pass  alternately  in  opposite  directions  ;  the 
rapidity  of  their  succession  may  be  judged  of  by  the  number 
of  clicks  heard  during  the  action  of  the  machine,  as  these 
vary  with  the  interruptions.  Arrangements  are  usually  pro- 
vided for  obtaining  rapidily  or  slowly  interrupted  currents 
by  springs  and  screws  in  the  one  form,  and  by  varying  the 
rate  of  rotation  in  the  other.  The  currents  from  the  inner 
and  outer  coils  are  employed  separately,  the  former  yielding 
the  "'  primary  induced  current,"  and  the  latter  the  "  second- 
ary induced  current."  This  primary  induced  current  (the 
"  extra  current"  of  physicists)  must  not  be  confounded  with 
the  primary  current  from  a  galvanic  battery ;  the  interven- 
tion of  a  coil  shows  that  we  have  to  deal  with  an  induced 
current.  Some  forms  of  apparatus  allow  of  the  use  of  these 
induced  currents  always  in  the  same  direction,  the  reverse 
currents  being  unused. 

A  third  form  of  electricity  (the  static)  may  be  named  the 
Fraxklixic  :  it  is  produced  by  friction :  glass  plates  or 
cylinders  are  rotated  against  cushions,  and  a  patient  placed 
on  an  insulated  stool  maybe  ••  charged"  from  these  machines, 
and  sparks  drawn  out  from,  or  passed  into,  his  spine  or  limbs. 
This  method  of  electrization  is  not  now  much  used,  it  is  only 
mentioned  here  to  prevent  any  confusion  from  its  omission. 

METHODS  OF  APPLICATIOX. 

The  methods  of  applying  electricity  as  well  as  the  selection 
of  the  kind  of  ciuTent.  vary  with  the  purpose  in  view :  both 
currents  are  often  required  in  diagnostic  tests.^ 

I.  The  Thermic  a^t)  GnEincAi  Effects  of  electricity  (galvanic 
cautery  and  electroljsis)  belong  more  to  surgery  than  medicine, 

'  As  the  uses  of  electricity  in  diagnosis  and  treatment  are  inti- 
mately related  to  each  other,  a  short  account  is  here  given  of  the 
methods  followed  in  the  treatment  of  cases  as  well  as  in  diagnosis. 
This  deviation  from  the  general  plan  of  the  book  is  more  willingly 
introduced,  as  the  student  has  still  some  difficulty  in  obtaining  in- 
formation on  this  subject. 

18* 


210  ELECTRICAL    INSTRUMENTS. 

but  as  the  electrolytic  treatment  of  thoracic  and  other  deep-seated 
aneurisms  is  now  sometimes  undertaken  by  physicians,  some  details 
may  be  given.  The  constant  current  from  a  battery  with  mod- 
erately large  plates  is  used ;  the  number  of  elements  employed 
should  not  be  great  (e.  g.,  six  or  eight  of  Stdhrer's  hospital  bat- 
tery) ;  the  ajjplication  should  be  prolonged  as  steadily  as  possible 
for  half  an  hour  to  an  hour  and  a  half;  occasionally  one  part  of 
the  operation  is  carried  out  with  less  or  more  elements,  according 
to  the  effect  produced;  the  point  of  the  needle  inserted  into  the 
aneurism  should,  if  possible,  just  reach  the  blood  current;  the 
needle  thus  inserted  should  be  insulated  except  for  about  half  an 
inch  at  its  point,  so  as  to  prevent  the  chemical  effect  on  the  tissues 
pierced,  and  tlie  danger  of  suppuration  from  this  cause.  Instead 
of  one  needle  two  or  more  may  be  inserted  in  connection  with  the 
same  pole.  The  needles  should  be  connected  with  the  positive 
pole.  (It  may  be  stated,  however,  that  some  prefer  the  negative 
pole,  and  some  operators  insert  needles  connected  with  both  poles 
into  the  aneurism  at  the  same  time,  and  some  use  needles  without 
insulation.)  The  circuit  is  joined  by  means  of  a  somewhat  large 
metal  plate  for  the  negative  pole,  covered  with  a  large  but  thin 
sponge,  wrung  out  of  salt  water  and  applied  in  the  vicinity  of  the 
tumor  after  the  skin  has  been  well  soaked.  The  operation  may  be 
repeated  at  intervals  of  a  fortnight  or  so.  On  withdrawing  the 
needle  a  little  blood  may  ooze  out,  calling  for  the  use  of  pressure 
or  cold.     Perfect  rest  must  be  enjoined  after  the  operation. 

II.  For  AcTI^•G  on  Muscles  both  the  galvanic  and  Faradic  currents 
are  used,  and  in  testing  paralyzed  muscles  for  diagnostic  purposes 
we  often  require  to  try  both  of  these  forms  of  electricity,  as  it  often 
happens  that  muscles  respond  easily  to  the  constant  galvanic  cur- 
rent, although  they  respond  only  imperfectly,  or  not  at  all,  to  the 
strongest  induced  or  Faradic  currents. 

We  may  act  on  muscles  by  stimulating  the  nerve  which  supplies 
them;  thus  we  may  act  on  the  muscles  of  the  forearm  or  hand  by 
currents  applied  to  the  nerve  in  the  ripper  arm.  "We  also  some- 
times stimulate  muscles  to  contraction  in  a  reflex  manner  by  a  cur- 
rent applied  at  a  distance,  as  when  we  act  on  the  cheek  and  cause 
contraction  of  the  eyelid.  As  a  rule,  however,  we  aim  at  a  more 
"localized  electrization,"  by  applying  the  poles  actually  over  the 
muscles  which  we  desire  to  simulate.  The  points  to  be  selected  are 
not  indifferent  ;  a  little  practice  shows  that  certain  spots  give  the 
command  of  certain  muscles  ;  it  has  been  ascertained  that  these 
correspond  with  the  points  at  which  the  motor  nerves  enter  the 
muscles  in  question.  These  spots  have  to  be  learned  by  experience 
and  observation,  and  charts  or  diagrams  have  been  made  by  Ziems- 
sen  and  others  showing  their  position  as  ascertained  in  actual  prac- 
tice. (Some  diagrams  are  reproduced  here  from  Ziemssen's  work  to 
facilitate  the  use  of  electrical  tests  in  diagnosis.  Those  who  wish 
further  details  as  to  the  face  and  other  j)arts,  may  refer  to  the 
original  work.  Die  Electricitdt  in  tier  Medicin,  Berlin,  1S57  ;  4th  edi- 
tion, 1872.  See  also  Dr.  Tibbits'  Map  of  Ziemssen^s  Motor  Points; 
Althaus's  Medical  Electricity,  3d  edition,  1873 ;  and  Brunelli,  Album 
illustr^  representant  la  Topographic  Nivro-muscidaire.  Paris,  1872.) 
The  poles  should  be  applied  by  means  of  wet  sponges,  the  skin  also 


FARADTZATION    OF    MUSCLES. 


211 


■being  well  moistened.  Witli  tlie  Faradic  battery  simple  water  suf- 
fices ;  with  the  galvanic  battery  it  is  better  to  use  alwav;_s  salt  water 
for  this  purpose.  Except  in  the  case  of  the  small  muscles  of  the 
face  and  hand  large  handles  (one  inch  in  diameter)  and  sponges 
answer  best ;  when  small  electrodes  are  used  they  may  be  covered 


Branch  of  the  median 
nerve  for  the  Piouiitor 
teres ^^**- 

Palmaris  longus 

^^ 
Flexor  carpi  ulnaris 


Flexor  sublimis  digi- 
torm  (middle  and  ring 
fingers) ^^     V^ 

Ulnar  nerve 

Flexor     sublimis     digi- 

torum  (index  and  little 

finger) 

Deep    branch    of   ulnar  [^gs-.     • 

nerve \        ^^      I 

Palmaris  bre  vis \      ^^       f 

Abductor  minimi  digiti. 
Flexor    brevis     minimi 

digiti 

Oppiinens  minimi  digiti. 

Lambricales  (2,  3,  and  S    ""-et^  ""'='=sfti&' 


Flexor  carpi  radialis. 


Flexor  profundus   digi- 
tomm. 


Flexor     sublimis    digi- 

torum. 

Flexor  longus  poUicis. 

Median  nerve. 

Abductor  pollicis. 

\ 
._>, Opponens  pollicis. 


Flexor  brevis  pollicis. 
Adductor  pollicis. 
Luml/ricalis  (1st). 


Fig.  23. — Ziemssen's  Motor  Points. 


with  moistened  chamois  leather  instead  of  sponges.  With  the 
Faradic  current  the  two  handles,  armed  with  the  sponges,  should  be 
held  near  each  other  ;  the  one  should  be  placed  on  the  spot  which 


212 


ELECTRTCAL    INSTRUMENTS. 


controls  the  muscle,  and  the  other  dabbed  over  the  surface  operated 
■upon  ;  or  if  preferred,  both  may  be  lifted  whenever  the  muscle 
contracts  ;  it  serves  no  good  purjjose  to  tetanize  the  muscles  by  a 
prolonged  contraction  such  as  would  occur  if  the  action  were  not  in- 
interrupted  in  this  way.  The  strength  of  the  current  is  of  great 
importance ;  we  ought,  therefore,  to  have  an  instrument  capable  of 


Supinator  longus 

Exteusor  carpi  radialis  longior 


Extensor  carpi  radialis  brevior 


Extensor     comrau 
rum 


nis     digito-J 


Extensor  indicis 

E  'tensor  iudicis  and  extensor  ) 

ossis  nietacarpi  poUicis I 

Extensor  ossis  metiicarpi  pol-  ) 

licis \ 

Extensor  prinii   internodii  pol- 
licis 


Flexor  long  us  pjUicis. 


Dorsal  iuterossei. 


r. 


L.  -- 


Extensor  carpi  uluaris. 
Extensor  minimi  digiti. 

Extensor  indicis. 


Extensor  secundi  inter- 
nodii poUicis. 


Abductor  minimi  digiti. 
Dorsal  interosseus  (4). 


Fig.  21. — Ziemssen's  Motor  Points. 


being  nicely  graduated  as  to  its  strength,  and  also  as  to  the  rapid- 
ity of  its  intermission  ;  it  is  desirable,  also,  to  have  one  which  leaves 
both  hands  free  for  the  manipulations  of  the  operation.  It  is  well 
to  try  the  force  of  the  current  on  ourselves  before  beginning  (on  the 
muscles  of  the  thumb  for  exami^le),  so  that  we  may  see  if  it  is 


ZIEMSSEN  S    MOTOR    POINTS. 


213 


strong  enongli  to  catise  contraction  and  not  so  strong  as  to  be  pain- 
ful. If  such  a  force  fails  to  act  on  the  paralyzed  muscle3,-we  should 
gi'aduaily  increase  the  strength.  Slowly  interrupted  currents  from 
the  primary  coil  are  preferi'ed  by  Duchenne  for  producing  muscular 
contractions.  We  aim  at  using  the  least  strength  sufficient  for  the 
purpose ;  this  avoids  pain  and  produces  a  more  natural  action  of 
the  muscles.  Sometimes  we  have  to  use  such  strong  currents  as 
to  cause  severe  pain,  but  this  is  comparatively  rare  and  indicates 
something  seriously  wrong  in  the  nerves  or  muscles.  Occasionally 
no  response  at  all  takes  place  to  the  strongest  currents.  It  is  some- 
times desirable  to  measure  accurately  the  difference  of  strength  in 
the  currents  required  for  calling  the  muscles  into  play  on  the  para- 
lyzed side,  as  compared  with  the  sound  side,  or  at  one  part  of  the 


Anterior  crnral  nerve , 

Obturator  nerve , 

Sartorius , 

Adductor  longns , 

Branch   of    crnral   nerve   to  ) 
quadriceps  extensor  cruris  \ 

Crurens  

Branch  of  crural  nerve,  to  vas 
tus  iuternas 


Tensor  fascise  femoris 
(bninch  of  superior 
gluteal  nerve). 

Tensor  fascise  femo- 
ris (branch  of  crural 

nerve). 

Eectus  femoris. 


Vastus  externus. 


Vastus  extern  us. 


Fig.  2". — Ziemssen's  Motor  Points. 


illness  as  compared  with  another.  This  difference  is  estimated  by 
the  graduated  scale  usually  attached  to  the  movable  coil  or  magnet 
in  an  induction  apparatus.  Special  precautions  are  required  to 
secure  uniformity  in  the  comparison,  such  as  are  described  in  using 
the  galvanic  current  in  this  process  of  testing.     (See  p.  217.) 

In  using  the  continuous  galvanic  current  for  acting  on  muscles,  we 
still  avail  ourselves  of  the  "points  of  election"  for  the  different 
muscles  ;  but  it  must  be  remembered  that  this  current  only  causes 
muscular  contraction  at  the  moment  the  circuit  is  joined  or  broken. 


214 


ELECTRICAL    INSTRUMENTS. 


A  current  from  a  constant  battery  passed  for  a  time  steadily  through 
a  muscle  does  not  cause  it  to  act  after  the  first  contraction  ;  but  on 
withdrawing  the  handles,  another  contraction  may  occur.  Hence 
if  we  wish  to  stimulate  the  muscles  to  contraction,  we  require  some 
means  of  interrupting  this  continuous  current.  This  may  be  done 
b.y  a  commutator  on  tlie  battery,  shutting  off  or  putting  on  the  cur- 
rent by  a  key,  or  by  removing  one  or  botli  of  the  sponges.  A  simi- 
lar effect  is  produced  more  gradually  and  gently  by  gliding  the 


Inferior  gluteal  nerve 

for  glnte\is  maxlmus 

Gr'^ac  sciatic  nerve.. . 

Loug  heiid  of  biceps. .  ■ 


Short  head  of  biceps.. 


Posterior  tibial  uerve. 

Peroneal  nerve 

Ga-;trocnemius  (exter- 
nal head) 


Soleus. 


Adductor  magnus. 

Seriiitendinosus. 

Semimembranosus. 


Gastrocnemius  (inter- 
nal head.) 


Fig.  2G. — Ziemssen's  Motor  Points. 


sponge  along  ;  in  this  way  the  current  is  joined  and  broken  at  the 
various  parts  passed  over  in  the  course  of  its  movement  ("'labile 
currents").  A  very  powerful  action  is  produced  by  reversing  the 
currents,  by  means  of  the  commutator,  and  less  suddenly  by  re- 
versing the  relative  position  of  the  sponges.  The  relative  position 
of  the  two  poles  is  not  a  matter  of  much  consequence  in  acting  on 
the  muscles,  except  in  the  estimation  of  the  force  required  in  dif- 
ferent parts,  as  will  be  explained  immediately.  It  is  not  necessary 
to  have  the  two  poles   ai^plied  close  together  in  acting  on  muscles 


ziemssen's  motor  points.  215 

with  the  galTanic  current ;  indeed,  it  is  usually  better  to  have 
them  at  a  distance,  one  of  them  being  placed  on  the  point  known 
to  command  the  muscle,  and  the  other  perhaps  on  the  nerve  trunk 
higher  up.  It  is  very  necessary  to  have  the  sponges  moistened 
with  salt  water,  and  the  skin  over  the  parts  operated  on  should 
also  be  well  soaked. 


Gastrocnemius  (inter- 
nal head) 


Flexor  communis  die 
itorum  lougus 


Posterior  tibial  nerve. 


Abductor  poUicis.. 


Fig.  27. — Ziemssen's  Motor  Points. 

A  great  difference  in  the  response  of  muscles  to  the  Faradic 
and  Galvanic  currents  is  occasionally  observed  ;  feeble  cur- 
rents from  a  galvanic  battery  may  act  wlien  the  strongest 
Faradic  currents  fail  to  do  so.  This  is  observed  in  certain 
cases  of  paralysis  from  injuries  to  the  nerves,  in  facial  para- 
lysis from   peripheral   causes,  in  infantile   paralysis,  and  in 


216 


ELECTRICAL    INSTRUMENTS. 


certain  cases  of  lead  palsy ;  this  constitutes  a  point  of  great 
importance  in  the  diagnosis,  prognosis,  and  treatment. 

But  further,  paralyzed  muscles  sometimes  respond  with 
preternatural  readiness  to  very  Aveak  currents  ;  ^.  e.,  they 
respond  to  currents  which  would  not   cause  any  noticeable 


Peroneus  longus 
Tibialis  anticus 


Extensor     louRus 
pollicis 


Bi-anch  of  pero- 
neal nerve  for 
exlensor  brevis 
digitorum 


Dorsal    inter, 
ossei 


Peroneal  nerve. 

Gastrocnemius 

(external  head). 
Sole  us. 

Extensor  commu- 
nis digitorum 
longus. 

■'^g^ea^ Peroneus  brovis. 

■^^SH Soleus. 

Flexor  loQgus  pol- 
licis. 


Extensor     brevis 
digitorum. 


Abductor    minimi 
disfiti. 


Fig.  2S. — Z  eiiifa'ien's  Motor  Point 


action  in  healthy  muscles  (two  or  four  elements).  This 
occurs  in  the  diseases  named  above,  and  especially  in  facial 
paralysis.  This  peculiarity  is  well  brought  out  in  such  cases 
by  applying  the  poles  of  an  induction  battery  to  the  sides  of 


FORMULA    OF    GALVANIC    CONTRACTILITY.       217; 

the  mouth,  when  the  mouth  is  at  once  drawn  to  the  sound 
side  ;  on  applying  now  the  poles  of"  a  constant  batteiy  to  tlie 
same  parts,  lifting  and  replacing  them  occasionally,  it  will 
be  seen  that  the  paralyzed  muscles  draw  the  mouth  to  their 
side  during  the  stimulation.  All  gradations  of  these  reac- 
tions are  found  in  different  cases  of  facial  paralysis  and  at 
different  stages.  This  unusually  ready  response  to  the  con- 
stant current  generally  diminishes  with  the  improved  con- 
tractility of  the  muscles  to  the  induced  current  which  takes 
place  in  favorable  cases  under  treatment  or  in  the  course  of 
time. 

The  explanation  of  this  difference  in  the  behavior  of  the 
paralyzed  muscles  under  the  two  different  forms  of  electrical 
stimulation  is  not  yet  clear,  but  it  is  in  some  way  connected 
with  the  instantaneous  or  extremely  brief  character  of  the 
induction  currents.  It  has  been  found  that  by  interrupting 
the  constant  current  very  rapidly,  while  applied  to  such 
muscles,  it  also  ceases  to  have  any  effect  on  the  muscles  in 
such  cases.  The  reaction  described  above  has  been  named 
by  Erb  the  "  reaction  of  degeneration."     (See  also  p.  223.) 

When  an  accurate  comparative  estimate  of  the  muscular 
contractility  is  desired,  we  must  proceed  in  such  a  way  as 
to  get  a  fair  comparison,  and  we  avail  ourselves,  if  possible, 
of  the  sound  muscles  on  the  opposite  side  for  this  purpose. 
Moreover,  in  using  the  galvanic  current  we  must  consider 
wdiich  pole  is  applied  to  the  nerve  or  muscle,  and  we  must 
also  notice  whether  the  contraction  occurs  on  breaking  or 
joining  the  circuit.  In  judging  of  any  change  in  the  re- 
sponse of  the  muscles  to  electricity,  we  must  consider  whether 
we  are  operating  on  the  nerve  trunk  or  on  the  muscles,  as 
the  reaction  may  differ  considerably  in  these  two  cases.  In 
carrying  out  the  comparison  one  pole  is  placed  on  some  in- 
different part  of  the  body  (the  sternum,  nape  of  the  neck, 
or  patella,  for  example),  and  the  other  is  applied  successively 
to  corresponding  spots  on  the  two  sides  of  the  body.  We 
notice  then  the  difference  in  the  readiness  or  force  of  the 
contraction,  and  we  note  how  much  more,  or  how  much  le.'s, 
is  the  strength  required  for  the  paralyzed  muscles  as  com- 
pared with  the  others.  In  using  the  galvanic  current  we 
vary  the  experiment  by  using  the  positive  and  the  negative 
pole  alternately  over  the  part  to  be  excited,  as  the  results 
ai-e  not  identical. 

In  connection  with  this  subject  electrical  authorities  some- 
times use  formulae  which  require  explanation,  especially  as 
19 


218  ELECTRICAL    INSTRUMENTS. 

the  words  represented  by  the  letters  in  some  books  are  partly 
Genuan,  and  very  confusing  to  readers  in  other  countries. 

An  =  Anode  (the  positive  pole,  sometimes  marked  +). 

Ka  ^  Cathode  (the  negative  pole,  marked  — ). 

S     :=  Schliessung,  i.  c,  closing  of  the  circuit. 

O    =  Oeffnung,  /.  e.,  opening  oi'  breaking  of  the  circuit. 

Z     =  Zuckung,  i.  e.,  contraction  or  twitch  of  the  muscle. 

Z'  =  The  accent  indicates  an  intensification. 

z     =  The  small  letter  indicates  a  feeble  contraction. 

Te  =  Indicates  Tetanic  contraction. 

The  symbols  are  combined  thus  as  in  the  formula  for  the 
action  of  strong  currents,  or 

"  Highest  grade,"  Ka  S  Te,  Ka  0  z,  An  S  Z,  An  0  z.    . 

These  four  formula;  are  read  thus  :  ( 1 )  On  the  closure  of 
the  current  the  cathode  produces  tetanic  contraction  :  (2)  on 
opening  the  current  it  produces  feeble  contraction  :  (3)  on 
closing  the  current  the  anode  produces  lively  contraction  : 
and  (4)  also  on  opening  the  circuit. 

"Lowest  grade,"  Ka  S  Z. 

"  Intermediate  grade,"  Ka  S  Z',  An  S  z  and  An  0  z.     (Erh.) 

In  connection  with  aural  electricity  the  symbol  Kl.  means 
Klang  (sound),  and  the  musical  symbols  •<  crescendo  or 
increasing  loudness,  and  >•  diminuendo  or  diminishing  loud- 
ness, are  also  used. 

With  the  induction  apparatus  we  use  the  currents  from 
the  secondary  coil  in  this  test,  and  the  trial  is  conducted  on 
the  same  principles. 

III.  AcTiox  ox  Sexsory  Nerves.  When  applying  Faradic  elec- 
tricity to  stimulate  muscles,  we  aim  at  doing  so  without  pain,  or  at 
least  with  a  minimnm  of  action  on  the  sensory  nerves  ;  hence  the 
directions  to  use  the  lowest  efficient  strengtli,  to  select  the  current 
from  the  primary  coil,  to  use  slow  interruptions,  to  have  large 
sponges  moistened  with  simple  water  for  electrodes,  to  apply  these 
near  together,  and  to  make  the  application  just  long  enough  to 
cause  muscular  contraction,  removing  and  re-applying  the  elec- 
trodes frequently. 

In  acting  on  sensory  nerves  zvith  the  Faradic  nirrent  these  direc- 
tions are  all  reversed  :  the  skin  should  be  left  dry  or  dusted  over 
with  violet  powder,  metal  handles  or  charcoal  electrodes  without 
sponges  are  nsed,  or  even  a  wire  brush  is  employed  for  one  of  the 
poles  :  strong  currents  from  the  secondary  coil  and  rapid  intermis- 
sions are  preferred,  and  the  brush  may  be  moved  up  and  down 
over  as  large  an  area  as  we  choose.  Such  applications  are  some- 
times employed  with  advantage  in  cases  of  ansesthesia,  to  rouse 
the  sensory  nerves,  and  tliey  are  sometimes  of  use  in  diagnosis. 
Insensibility  to  this  irritation,  or  diminished  electrical  sensibility 


USE    IN    ANAESTHESIA    AND    NEURALGIA.  219 

as  it  is  called,  is  a  striking  feature  in  certain  cases  of  hysterical 
paralysis  and  anaesthesia,  and  in  some  other  aJfections.  While 
testing  the  muscles  in  such  cases  we  can  usually  guess  by  the  be- 
havior of  the  patients  whether  or  not  they  feel  the  current  to  a 
normal  or  usual  extent,  and  we  taay  subsequently  apply  the  test 
more  efficiently  as  just  described. 

The  wire  brush  is  also  used  by  some  for  its  counter  irritant  eflfect 
'and  its  reflex  action.  Brushing  over  the  spine  in  certain  spinal 
affections,  brushing  the  cheek  and  larynx  in  facial  paralysis  and 
hysterical  aphonia,  and  applying  very  strong  currents  in  neuralgia 
(electric  moxa)  are  methods  sometimes  practised,  but  all  of  tliem 
are  painful  and  must  be  used  with  great  caution.  This  treatment 
has  also  some  influence  over  the  vascular  system,  and  it  sometimes 
improves  the  temperature  of  a  cold  limb. 

The  Galvanic  current  is  occasionally  felt  to  be  painful  in  cases 
which  are  insensible  to  strong  induced  currents  (hysterical  paraly- 
sis), so  that  the  form  of  electricity  employed  in  testing  should 
always  be  noted.  Charcoal  electrodes  suit  very  well  in  applying 
this  test  to  the  skin.  The  sensation  experienced  from  the  constant 
current  differs  from  that  felt  on  using  the  interrupted  current :  the 
latter  gives  rise  to  a  tingling  feeling,  the  former  produces  a  burn- 
ing or  stinging  sensation.  On  galvanizing  the  spine  with  a  mode- 
rate current  we  sometimes  detect,  while  applying  the  moist  sponges, 
that  there  are  one  or  two  tender  spots  over  certain  vertebrae,  /.  e., 
spots  specially  sensitive  to  this  current.  These  spots  often  agree 
exactly  with  the  spots  discovered  to  be  tender  to  the  touch,  but 
sometimes  this  test  reveals  tender  parts  more  delicately  than  pres- 
sure or  the  hot  sponge.  Care  must  be  taken  that  the  various  parts 
of  the  skin  are  equally  moist  in  applying  this  test,  and  the  press- 
sure  of  the  electrode  also  must  be  made  quite  equal  in  the  different 
parts  before  we  conclude  that  this  sensitiveness  really  exists. 

IV.  Applied  foe  MrsccLAR  Rheumatism  and  myalgia,  both  kinds 
of  electricity  are  occasionally  employed.  The  induced  currents  are 
used  in  such  cases  either  with  wet  sponges  for  the  stimulation  of 
the  muscles,  or  with  the  wire  brush.  When  the  constant  current 
is  employed,  and  it  is  usually  to  be  preferred,  moderate  currents 
are  used,  and  the  poles  are  made  to  glide  gently  over  the  painful 
surface.     (Lumbago,  stiff-neck,  muscular  pleurodynia.) 

V.  FoK  Neuralgia,  induced  currents  of  great  strength  applied 
with  the  wire  brush  (electric  moxa)  are  used  by  some,  but  as  they 
are  very  painful  and  as  counter-irritation  in  less  painful  forms 
often  serves  the  same  purpose,  this  method  is  seldom  to  be  recom- 
mended. 

The  constant  galvanic  current,  on  the  other  hand,  can  be  applied 
in  such  cases  with  little  or  no  discomfort,  and  is  often  most  ser- 
viceable. The  current  should  be  strong  enough  to  be  felt,  but 
should  not  cause  pain  (6 — 10  elements  for  the  face,  8 — 20  for  the 
limbs)  :  the  current  should  be  passed  without  any  interrui^tion, 
the  sponges  being  held  steadily  without  any  movement  or  shak- 
ing. Difference  of  opinion  exists  as  to  the  direction  in  which  the 
current  should  be  applied ;  a  balance  of  opinion  exists  in  favor 
of  (1)  a  descendiny  current   (/.  e.,  a  current  from  the  nerve  centres 


220  ELECTRICAL    INSTRUMENTS. 

towarrls  the  periphery),  and  (2)  of  applying  the  positive  poh^over 
the  painfnl  jjart,  witliont  regard  to  the  direction  of  the  current 
(polar  method).  These  two  methods  are  not  incompatible.  Tlie 
skin  should  he  well  moistened  with  salt  water  for  applications  of 
this  kind,  and  as  pressure  with  the  electrodes  is  often  painful,  the 
eifect  can  be  increased  by  having  the  spots  selected  for  the  appli- 
cation dressed  with  salt  water  dressings  for  an  hour  or  two  before, 
the  current  is  applied.  The  duration  of  the  application  should  be 
considerable,  5,  10,  or  20  minutes  at  a  time  :  but  on  the  face  the 
duration  is  much  less,  as  giddiness  is  aj)t  to  be  produced  in  this 
situation,  and  on  its  occurrence  we  must  stop  the  application,  at 
least  for  a  few  minutes.  In  applying  and  removing  the  electrodes, 
or  increasing  or  diminishing  the  strength  of  the  current,  we  aim 
at  doing  so  with  as  little  "  shock"  as  possible  ;  this  is  done  either 
by  gradually  increasing  or  relaxing  the  pressure  of  the  electrodes 
on  the  parts,  or  by  adding  and  removing  the  additional  elements 
gradually. 

For  cases  of  neuralgia,  a  battery  with  relatively  large  plates  and 
small  chemical  action  should  be  selected,  and  the  patient  should 
remain  at  rest  for  a  time  after  the  application,  especially  in  cases 
of  sciatica.     The  sittings  should  be  repeated  daily  if  possible. 

VI.  The  Nervous  Cektres  can  be  acted  on  by  the  constant  cur- 
rent applied  to  the  head  and  spine,  and  patients  often  experience 
giddiness.  Hashes  of  light,  and  a  metallic  taste  in  the  mouth  when 
the  head  or  the  upper  part  of  the  spine  or  neck  is  operated  on. 
For  the  head  weak  currents  must  always  be  used,  not  more  than 
about  ten  elements  at  the  most,  and  the  applications  must  be  short 
(half  a  minute  to  three  minutes),  and  they  must  be  stopped  on  the 
occurrence  of  giddiness.  The  electrodes  are  placed  sometimes  on 
each  side  of  the  head,  on  the  temples  or  mastoid  processes,  or  one 
on  the  nape  of  the  neck  and  the  other  on  the  brow  or  on  one  of  the 
mastoid  processes.  No  rule  can  be  given  as  to  the  direction  of  the 
current  in  such  applications. 

For  the  spinal  cord  a  larger  number  of  elements  may  be  used  and 
the  time  prolonged  to  fifteen  minutes  or  more.  The  part  operated 
on  is  determined  by  the  nature  of  the  case.  As  a  rule,  in  spinal 
cases  descending  currents  are  preferred,  but  in  locomotor  ataxy  the 
ascending  current  seems  to  give  better  results.  The  sponges  and 
skin  must  be  well  moistened  with  salt  water,  and  the  electrodes 
should  be  held  very  steadily  to  avoid  all  shocks  as  much  as  possi- 
ble. Sometimes  one  pole  is  applied  to  the  spine  and  the  other  to 
the  region  of  the  plexuses  or  nerve  trunks ;  or  one  to  the  region  of 
the  plexus  and  the  other  to  the  main  nerve  in  the  limb,  as  this 
stimulation  may  have  an  indirect  action  on  the  cord. 

Galvanism  to  the  spinal  cord  and  brain  should  as  a  rule  be 
avoided  in  all  acute  or  recent  cases.  Faradization  is  not  to  be  ap- 
plied to  the  brain  or  spinal  cord. 

The  sympathetic  in  the  neck  may  be  acted  on,  it  is  supposed,  by 
placing  one  of  the  electrodes  over  its  upper,  middle,  or  lower  cer- 
vical ganglion,  and  the  other  ou  the  cervical  region  of  the  spine, 
at  its  lower  part,  or  on  the  supra-sternal  notch.  Certainly  some 
very  curious  results  follow  such  applications,  flashes  of  light,  gid- 
diness, and  bilateral  convulsive  movements  ;    but  it  is  not  qnite 


SPECIAL    APPLICATIONS.  221 

certain  that  all  this  is  due  to  stimulation  ot  the  sympathetic,  as 
other  important  nerves  are  in  the  same  region. 

Operations  of  this  kind  must  he  carried  out  with  great  caution ; 
only  weak  currents  should  be  used,  and  short  applications,  as  in 
the  case  of  the  brain. 

Galvanization  of  the  sympathetic  is  recommended  in  many  ob- 
scure cerebral  and  spinal  affections  for  its  supposed  induence  on 
the  nutrition  of  these  great  nervous  centres. 

VII.  Foe  iMPKOvixfiTHE  Nuteitiox,  the  circulation,  and  the  tem- 
perature of  a  part,  any  form  of  electricity  which  improves  the  state 
of  tlie  muscles  and  nerves  may  be  recommt-nded,  but  the  constant 
current  has  usually  a  more  marked  induence  in  lessening  the  cold- 
ness of  a  limb  so  often  complained  of  in  the  atrophic  forms  of 
paralysis.  Certainly  this  kind  of  electricity  affects  the  circulation, 
and  it  is  possibly  in  this  way  that  it  produces  a  beneficial  influence 
on  the  nutrition  of  the  tissue  of  the  nerves,  the  brain,  and  the 
spinal  cord. 

YIII.  Special  Oegans  require  some  special  arrangements  for  the 
application  of  electricity.  The  Eye  is  acted  on  when  we  seek  to 
affect  the  optic  nerve  by  applying  (say)  the  positive  pole  of  a  con- 
stant battery  to  the  forehead,  to  the  mastoid  process,  or  to  the  nape 
of  the  neck,  and  gliding  the  other  pole  along  the  angles  of  the  orbit, 
or  by  passing  the  current  through  the  temples.  The  ocular  mus- 
cles may  also  Vje  galvanized  or  faradized  by  bringing  a  small  elec- 
trode into  their  vicinity.  Eur  is  galvanized  or  faradized  by  filling 
the  meatus  with  salt  water,  and  introducing  an  insulated  electrode 
into  the  fluid  while  the  head  is  held  down  sideways,  the  other  pole 
heing  held  by  the  patient  in  the  hand  of  the  opposite  side.  The 
same  care  must  be  exercised  in  using  such  methods  as  in  operating 
on  the  brain.  Applications  to  the  sympathetic  in  the  neck  are 
sometimes  made  for  these  organs.  Specially  shaped  and  insulated 
electrodes  are  used  for  direct  application  to  the  laryngeal  muscles. 
Stimulation  of  the  phrenic  nerve  for  the  excitation  of  the  respiration 
sometimes  saves  life  in  chloroforru  poisoning,  and  its  use  is  indicated 
in  some  other  forms  of  asphyxia.  Metallic  buttons  as  electrodes, 
with  fine  moist  sponges  or  leather  coverings  are  applied  on  either 
side  of  the  neck,  over  the  lower  end  of  the  scalenus  muscle,  on  the 
outer  border  of  the  sterno-mastoid,  and  this  muscle  should  be 
pressed  a  little  inwards  ;  the  head  and  shoulders  should  be  fixefl 
hy  an  assistant,  and  expiration  may  have  to  be  assisted  by  pres- 
sure on  the  abdominal  walls.  The  duration  of  one  application  (f.  e., 
for  each  contraction)  should  not  be  more  than  twenty  seconds. 
The  current  should  be  from  an  induction  apparatus,  and  should  be 
strong  enough  to  cause  contraction  of  the  muscles  of  the  operator's 
thumb  ;  if  this  does  not  succeed  in  causing  an  inspiratory  gasp, 
stronger  currents  may  be  tried,  as  the  excitability  sometimes  dimin- 
ishes rapidly  in  asphyxia.  If  induced  currents  fail  to  act,  the 
continuous  current  has  been  recommended  as  a  last  resource.  The 
abdominal  muscles  and  even  the  bowels  and  bladder  and  uterus  may  be 
acted  on  to  some  extent  from  without,  the  poles  heing  applied  to 
various  parts  of  the  abdomen  and  back.  For  the  rectum,  a  more 
efficient  plan  is  to  inti-oduce  an  insulated  electrode  within  the  towel, 

19* 


222  ELECTRTOAL    INSTRUMENTS. 

and  to  apply  tlie  other  to  the  abdominal  parietes.  Both  forms  of 
electricity  may  be  i\sed  in  tliis  way.  The  bladder  is  likewise  some- 
times acted  on  by  means  of  an  insulated  electrode  introduced  into 
its  cavity,  the  other  being  applied  within  the  rectum  or  above  the 
pubes.  If  the  continuous  current  be  used,  the  generation  of  gas 
from  the  decomposition  of  the  urine  may  lead  to  annoyance  if  the 
electrode  be  within  the  bladder.  For  incontinence  of  urine  a  strong 
current  from  a  continuous  battery  (from  as  many  elements  as  can 
be  borne,  fifty  or  more  of  Daniell's  or  Smee's)  may  be  passed  up- 
wards, the  negative  pole  being  applied  to  the  perineum  just  behind 
the  scrotum,  and  the  positive  to  the  dorsal  or  lower  cervical  regi<m 
of  the  spine.  The  uterus  is  sometimes  acted  on  in  the  same  way 
as  the  bladder.  In  impotence  the  testicles,  the  muscles  of  the  penis, 
or  the  mucous  membrane  of  the  glans  may  be  acted  on  by  the  con- 
stant or  by  the  interrupted  current,  according  as  the  error  seems 
to  be  in  the  secreting  power  of  the  testicle,  the  defective  state  of 
the  erector  muscles,  or  the  sensitiveness  of  the  glans. 

DIAGNOSTIC  SIGNIFICANCE  OF  ELECTRICAL  TESTS. 

Contractility  of  the  muscles  to  the  induced  current  may 
remain  but  little  impaired  in  cerebral  pai-alysis,  in  rheumatic 
paralysis  (apart  from  affections  of  the  facial  nerve),  in  hys- 
terical paralysis,  in  paralysis  of  the  extensor  muscles  of  the 
fingers  and  wrists  from  pressure  on  the  arm  (arising  from  the 
use  of  splints  and  crutches,  or  from  lying  on  it  during  sleep), 
in  locomotor  ataxy,  in  general  paralysis,  in  pseudo-hyper- 
trophic  muscular  paralysis,  in  wasting  palsy,  and  in  certain 
cases  of  paraplegia  from  spinal  lesions.  Any  of  the  above 
forms  of  paralysis,  however,  may  exist  so  long,  and  may  lead 
to  such  disuse  of  the  muscles  that  wasting  and  destruction 
of  the  muscular  tissues  proceed  to  such  an  extent  that  they 
no  longer  respond  to  this  stimulus,  or  do  so  only  feebly.  This 
is  especially  noticed  in  advancing  cases  of  wasting  palsy, 
where  the  response,  of  course,  is  diminished  in  proportion  to 
the  actual  wasting,  although  preserved  in  the  remaining  por- 
tion of  muscle.  While  this  contractility  to  the  induced  cur- 
rent exists  unimpaired,  we  infer  that  there  is  no  serious  lesion 
of  the  muscles  themselves,  of  the  nerve  trunk  supplying 
tliem,  or  of  the  nervous  centre  at  its  point  of  junction  with 
the  nerves  in  question. 

Abolition  or  diminution  of  the  contractility  to  the  in- 
duced current  occurs  in  paralysis  from  such  serious  lesions  of 
the  nerves  as  results  from  wounds,  or  from  compression  of 
the  nerve  trunk  by  tumor,  or  exostosis,  or  certain  exudations. 
In  the  case  of  the  facial  nerve  an  exudation  in  the  osseous 
canal  may  give  rise  to  serious  compression  of  this  kind,  or 


STGNIFICANCE    OF    ELECTRICAL    TESTS.  223 

caries  may  lead  to  the  destruction  of  the  nerve.  In  infan- 
tile paralysis  also,  and  in  other  forms  of  spinal  disease  with 
destruction  of  the  cord  at  the  roots  of  the  nerves,  or  of  the 
cells  connected  with  tliem  in  the  anterior  cornua,  this  con- 
tractility is  lost  or  diminished.  Lead  palsy  is  also  usually 
characterized  by  this  peculiarity.  The  loss  or  diminution  of 
the  muscular  contractility  to  the  induced  current  occurs  with 
great  rapidity  in  all  the  above  cases,  and  usually  exists  from 
the  very  time  the  paralysis  becomes  distinctly  declared, 
differing  therein  from  the  loss  of  contractility  which  is  de- 
veloped slowly  in  connection  with  mere  disuse  or  atrophy. 
(See  next  section  also.) 

Preservation  of  contractility  to  galvanic  current,  and  loss 
of  contractility  to  induced  current.  This  is  commonly  ob- 
served in  the  cases  just  noticed  in  the  previous  section,  at 
least  in  their  eaidier  stages.  It  frequently  happens  in  cases 
of  facial  paralysis  especially,  and  also  in  infantile  paralysis 
and  lead  palsy,  that  the  response  to  the  continuous  current 
is  even  livelier  on  the  paralyzed  than  on  the  sound  side. 
This  reaction  usually  concurs  with  some  lesion  of  the  nerve 
trunk  or  of  the  nerve  root  involved.  (Erb's  reaction  of  de- 
generation.) 

Loss  of  miiscular  contractility  to  both  currents  is  found  in 
advanced  paralysis,  from  any  cause,  which  has  led  to  the 
destruction  of  the  muscular  tissue  or  to  its  fatty  degenera- 
tion ;  such  destruction  may  be  inferred  from  this  test.  Espe- 
cially does  this  occur  in  old  spinal  paralysis  with  atrophy  ; 
in  bad  cases  of  infantile  atrophic  paralysis,  in  the  last  stage 
of  pseudo-hypertrophic  muscular  paralysis  and  wasting  palsy, 
and  also  in  lead  paralysis.  It  occurs  rapidly  also  in  serious 
mechanical  lesions  of  the  nerve  trunks  from  wounds  and 
injuries. 


224 


CHAPTER  VIII. 
INSANITY.' 

Before  considering  the  forms  of  insunity,  it  is  desirable 
tlijit  the  meaning  of  certain  terms,  which  are  of  constant  use 
in  describing  mental  disorders,  should  be  clearly  understood. 
These  are — 

Illusions,  Hallucinations,  and  Delusions — Illu- 
sion and  Hallucination  have  reference  only  to  disordered 
perceptions.  Both,  separately  or  together,  may  exist  without 
insanity.  In  order  to  the  occui-rence  of  an  Illusion,  a  real 
impression  must  be  produced  on  the  sensorium ;  but  this 
impression  appears  in  consciousness  very  different  from  the 
actual  fact.  The  impression  in  most  cases  comes  from  with- 
out, and  is  transmitted  through  one  or  other  of  the  senses 
(by  far  the  most  frequently  through  those  of  hearing  and 
sight) ;  but  it  may  spring  from  one  of  the  internal  organs. 
On  the  other  hand,  an  Hallucination  arises  when  no  impres- 
sion has  been  produced  on  any  of  the  senses,  and  it  is  equally 
independent  of  visceral  sensations.  It  is  entirely  a  new 
creation  due  to  an  abnormal  condition  of  the  sensorium  itself. 
The  varying  morbid  states  of  this  great  centre,  or  of  these 
great  centres  of  sensation,  seem  in  the  consciousness  of  the 
individual  to  be  impressions  that  have  come  in  natural 
course  from  the  organs  of  special  or  general  sensation.  Briefly 
expressed.  Illusions  are  objective  in  relation  to  the  sensorium, 
whereas  Hallucinations  are  subjective.  Thus,  if  a  human 
voice  be  heard  by  one  when  others  hear  only  the  tolling  of  a 
bell,  that  is  an  Illusion ;  but  should  it  be  heard  when  there 
is  no  sound  of  any  kind,  that  is  an  Hallucination :  and  so 
with  the  other  senses.  It  is  sometimes  difficult  to  distinguish 
between  these  two  forms  of  morbid  perception,  especially 
when  they  relate  to  general  sensation.  Whatever  their 
origin,  should  the  patient's  reason  still  enable  him  to  discard 
them  as  false  and  unsound,  he  is  sane  in  relation  to  them ; 

1  The  following  writers  may  be  consulted  with  advantage :  Buck- 
nill  and  Tuke,  Blandford,  Maudslej,  Griesinger,  and  Ireland. 


CHIEF    FORMS    OF    INSANITY.  225 

and  this  frequently  happens  with  illusions,  though  seldom 
with  hallucinations.  If  he  cannot  be  convinced  of  their  un- 
reality he  is  very  generally  insane,  but  not  always,  as  early 
training,  peculiar  religious  views,  and  other  special  circum- 
stances may  account  for  the  apparent  mental  unsoundness. 

Delusion,  strictly  regarded,  pertains  exclusively  to  the 
highest  mental  functions,  and  has  no  direct  connection  with 
sensation  in  any  form.  A  man  who  asserts  he  is  ten  thousand 
years  old,  or  that  he  is  the  Almighty,  labdrs,  therefore,  under 
Delusion  proper.  But  tliough  the  term  is  occasionally  em- 
ployed in  this  restricted  sense,  to  distinguish  it  from  those 
already  described,  it  is  also  commonly  used  generically  to  in- 
clude them  all.  It  may  thus  be  correctly  applied  to  either 
Illusions  or  Hallucinations,  if  they  are  the  result  of  disease, 
and  are  not  corrected  by  reason.  In  a  court  of  law,  as  a 
matter  of  expediency,  it  is  advisable  to  avoid  the  latter  terms, 
and  to  designate  all  morbid  ideas  of  lunatics  as  "  insane  de- 
lusions ;"  the  word  delusion  hy  itself  being  often  popularly 
used  to  describe  a  mere  unfounded  belief. 

The  chief  forms  of  Insanity,  according  to  the  best 
established  classification,  are  Mania,  Melancholia,  Monoma- 
nia, Dementia,  and  Idiocy.  Mania  implies  considerable 
general  excitement,  which  is  usually  accompanied  by  inco- 
herence of  ideas,  delusions,  and  violent  conduct ;  but  there 
are  varieties  of  mania  without  incoherence  or  distinct  delu- 
sions. In  Melancholia  there  is  mental  depression  with  delu- 
sion generally  limited  to  one  or  to  a  small  number  of  subjects. 
There  is  also  simple  melancholy  without  delusion.  In  Mo- 
nomania there  is  no  depression,  but  generally  exaltation  or 
perversion  of  feeling ;  delusion  is  restricted  to  one  or  (much 
more  commonly)  to  a  small  number  of  subjects,  all  of  the 
same  character;  but  the  intellect,  though  often  wonderfully 
clear  and  acute  in  other  directions,  is  not  altogether  free  out- 
side the  morbid  circle.  In  Dementia  the  powers  of  the  mind, 
previously  of  average  vigor,  are  enfeebled  or  destroyed.  In 
Idiocy  the  original  mental  development  has  fallen  far  short 
of  the  normal  standard,  either  through  a  congenital  cause  or 
one  occurring  in  early  childhood.  Imbecility  is  this  state  in 
a  minor  degree. 

Premonitory  mental  symptoms  almost  ahvays  precede  an 
attack  of  any  of  the  acquired  forms  of  insanity.  These  are 
to  be  looked  for  in  disturbance  of  the  emotional  powers  rather 
than  in  an  abnormal  state  of  the  intellect, — the  latter  condi- 
tion being  subsequent  to  the  former.     There  is  usually  a  pre- 


226  INSANITY. 

liniinarj  period  of  depression,  and  this  is  often  seen  even 
where  the  fully  pronounced  derangement  is  a  state  of  excite- 
ment. The  patient  has  a  vague  feeling  of  discomfort,  of 
mental  weariness  and  pain.  There  is  unwonted  irritability; 
trifles  that  would  formerly  be  unheeded,  now  fret  and  worry; 
those  most  loved  and  bound  by  the  closest  ties  of  kindred  are 
regarded  with  suspicion,  jealousy,  and  aversion ;  a  feeling  of 
baseless  apprehension,  with  sometimes  a  painful  anticipation 
of  insanity,  are  experienced  :  unusual  vacillation  of  purpose 
may  be  a  feature  ;  and  the  sufferer,  particularly  in  the  pre- 
monitory stage  of  melancholia,  may  likewise  have  a  weari- 
ness of  the  world,  and  a  longing  for  death.  Such  feelings 
and  dispositions  in  various  combinations  form  the  foundation 
of  morbid  sentiment  on  which  delusion,  in  its  varied  forms, 
is  based.  In  some  cases  of  mania,  however,  there  is  no 
preliminary  depression  and  the  initiatory  stage  is  one  of 
gradually  increasing  excitement. 

Mania In  acute  mania  the  preliminary  stage  of  depres- 
sion with  irritability,  should  it  exist  at  all,  is  not  generally  of 
long  duration.  About  the  period  when  it  is  giving  place  to 
excitement  there  is  occasionally  a  general  susceptibility  of 
the  nervous  system,  characterized  by  exceeding  sensitiveness 
to  sharp  and  loud  noises,  and  to  bright  light,  and  also  by  a 
disposition  to  sudden  and  violent  starting  of  the  legs  and  even 
the  whole  frame,  especially  when  about  to  fall  asleep.  Some 
people  are,  however,  subject  to  similar  startings  in  a  minor 
degree  from  slight  causes,  such  as  derangement  of  the  diges- 
tive system,  and  many  epileptics  suffer  from  them  in  the  in- 
tervals between  the  fits. 

The  mental  excitement  may  show  itself  very  gradually, 
or  it  may  be  quite  sudden  in  its  onset.  The  disorder  of  the 
intellect  occurs  in  degrees  varying  from  scarcely  noticeable 
rambling  in  conversation  to  complete  incoherence.  Illusions 
and  hallucinations,  particularly  of  sight,  as  well  as  delusions 
proper,  are  very  common,  though  mania  may  exist  without 
any  of  them.  A  distinguishing  feature  of  the  morbid  ideas 
is  their  evanescence ;  they  are  not  fixed,  even  though  the 
same  kind  of  fancies  may  recur  from  time  to  time.  Besides 
the  intellectual  disturbance,  there  is  general  restlessness  and 
impatience,  a  hurry,  a  confusion,  and  an  unusual  disposition 
to  action.  Some  patients  are  in  a  happy,  joyous  mood ; 
others  are  angry  and  irritable  ;  not  a  few  alternate  between 
these  states.  The  conduct  is  often  violent  and  disgusting : 
shouting,   singing,   gesticulating,   quarrelling    and    fighting, 


ACUTE    MANIA.  227 

tearing  clothes,  smearing  the  person  and  berlroom  with  feces, 
and  other  filthy  actions.  Outrageous  conduct  is  often  first 
manifested  during  the  night.  It  is  to  be  observed  that  both 
delusions  and  actions  are  stamped  bj  the  character  of  the 
prevailing  morbid  emotion. 

From  the  very  commencement  of  the  illness  sleep  is  almost 
always  deficient  in  amount,  and  is  occasionally  absent  alto- 
gether ;  or,  what  is  more  common,  it  is  obtained  for  half  an 
hour  or  an  hour,  now  and  again,  the  patient  awakening  in 
no  respect  impi'oved.  Terrifying  dreams  often  disturb  these 
brief  snatches  of  sleep.  The  appetite,  though  frequently 
considerably  impaired  in  the  early  stage  of  the  disorder,  is 
usually  good  when  it  is  fully  developed,  and,  indeed,  is  some- 
times abnormally  keen.  But,  notwitlistanding  the  large 
quantities  of  food  consumed,  nutrition  is  not  well  maintained, 
and  many  patients  distinctly  fall  off  in  condition.  The 
tongue  is  moist  and  clean  in  many  cases,  but  may  be  furred 
and  yellow,  in  which  case  the  breath  will  probably  also  be 
unpleasant.  The  bowels  are  generally  confined,  and  the 
stools  are  apt  to  be  offensive,  but  occasionally  a  tendency 
to  diarrhoea  is  seen.  Thirst  is  seldom  present.  The  urine 
is  commonly  diminished  in  quantity,  increased  in  specific 
gravity,  of  acid  reaction,  with  an  excess  of  phosphates  ;  but 
occasionally  it  is  neutral  or  even  alkaline,  and  the  amount 
may  be  normal.  Excitement  of  the  sexual  instinct,  which 
is  not  rare,  may  show  itself  in  masturbation  and  indecent 
exposure  of  the  person.  Menstruation  is  usually  altogether 
or  in  a  great  measure  suppressed.  The  menses  generally 
return  coincidently  with  recovery-,  but  their  appearance  does 
not  always  herald  the  advent  of  convalescence  ;  and,  on  the 
other  hand,  mental  health  may  be  restored  while  they  con- 
tinue in  abeyance.  In  the  majority,  the  skin  is  somewhat 
harsh  and  dry,  but  it  is  quite  common  to  find  it  soft  and 
moist ;  its  secretions  are  often  disagreeable  in  odor.  Should 
the  patient's  exertions  be  violent,  the  general  temperature 
may  be  temporarily  elevated,  but  ordinarily  it  is  little  if  at 
all  above  the  average.  Increased  heat  of  head,  especially  of 
the  vertex,  is  often  noticeable.  In  a  few  cases  there  is  ex- 
cessive salivary  secretion.  The  pulse,  as  a  general  rule,  is 
from  eighty  to  ninety  in  frequency,  and  of  diminished  volume ; 
but  there  are  many  exceptions,  some  being  a  few  beats  above 
and  others  below  that  range.  In  the  early  stage  the  con- 
junctivae will  often  be  found  somewhat  injected  and  yellowish, 


228 


INSANITY. 


but  tliis  is  not  common  when  the  excitement  is  fully  estab- 
lished; the  as[)ect  is  then  frequently  bright  and  glistening. 

Acute  mania  occurs  occasionally  in  a  more  asthenic  form 
than  that  just  described.  The  physical  symptoms  are  indi- 
cative of  greater  debility :  the  pulse  is  weak  and  quick,  the 
pupils  wide,  the  face  pale,  and  there  is  often  distinct  antemia. 
The  psychical  disturbance  is  also  more  uuiformly  high.  In 
short,  this  form  holds  a  middle  position  between  the  sthenic 
and  the  one  next  to  be  considered ;  and  there  is  a  gradation 
of  cases  connecting  all  three. 

The  variety  now  before  us  corresponds  in  some  respects 
with  severe  delirium,  and  is  hence  known  as  Actite  delirious 
mania.  The  incoherence  in  this  state  is  complete ;  the  pa- 
tient talks  or  shouts  in  fragmentary  disconnected  sentences, 
and  the  excitement  is  very  high.  There  are  no  definite  de- 
lusions, the  mental  disorder  being  apparently  too  great  for 
formulated  thought  of  any  kind,  but  in  some  cases  indica- 
tions of  transitory  hallucinations  and  illusions  are  observable 
in  the  midst  of  the  ravings.  Such  patients  are  generally 
violent  and  destructive  and  of  dirty  habits,  but  their  acts 
differ  from  those  of  ordinary  acute  mania  in  partaking  more 

^of  blind  fury,  with  less  distinct  consciousness  in  the  agents. 

*  The  physical  symptoms  are  proportionately  intensified. °  The 
pulse  is  very  quick  and  weak,  the  conjunctiva?  ai-e  injected, 
and  the  pupils  are  often  smaller  than  the  normal,  tlie  skin  is 
parched  and  hot,  the  tongue  is  dry,  tending  to  brown,  the 
appetite  is  in  abeyance,  and  there  is  usually  a  sickening 
odor  from  the  breath,  a  degree  of  thirst  is  common,  and  there 
is  an  almost  total  absence  of  sleep.  There  is  a  high  mortality 
in  this  condition,  but  should  the  tendency  to  death  from  ex- 
haustion be  overcome,  the  patients  usually  make  excellent 
and  speedy  recoveries  from  their  mental  disorder. 

Mania  transitoiHa  is  a  variety  which,  as  its  name  implies, 
passes  away  quickly—even  in  a  few  liours,  or  at  longest  in  a 
day  or  two.  The  symptoms  are  those  of  the  most  acute 
form  of  sthenic  mania.  The  seizure  occurs  suddenly,  and  is 
most  frequently  met  with  as  a  result  of  mental  shock  or  of 
intoxicating  liquor  in  persons  who  are  of  the  "  insane  tem- 
perament"—who  in  their  ordinary  health  are  excitable,  ner- 
vous, odd  in  their  opinions,  and  peculiar  in  their  general 
conduct — this  condition  being  usually, the  fruit  of  heredity. 
It  is  also  apt  to  show  itself  in  individuals  who  have  had  sun- 
stroke or  whose   heads   have   been   injured  (possibly  many 

years  previously),  after  a  slight  excess  in  alcohol,  or  from  a 


RELATION   OF   INSANITY   TO    VARIOUS   DISORDERS.     229 

moral  cause,  such  as  sudden  and  great  provocation.  When 
due  to  alcohol  this  is  the  "  mania  a  potu,"  properly  so  called. 

Chronic  mania  may  be  considered  as  established  when — 
the  symptoms  of  the  acute  stage  having  somewhat  subsided, 
after  some  months'  duration — the  delusive  ideas  are  more 
definitely  formed  than  at  first,  the  incoherence  is  still  consid- 
erable, though  somewhat  less,  and  the  excitement  is  not  so 
constant  but  more  paroxysmal  in  its  character.  At  this 
period,  illusions  and  hallucinations,  especially  of  hearing,  are 
commonly  present;  but  one  or  more  of  the  other  senses  also 
are  frequently  involved  in  the  same  patient.  Tiie  bodily 
condition  is  now  generally  good.  This  is  the  state  of  a  large 
proportion  of  the  inmates  of  asylums.  It  may  last  for  many 
years  in  much  tlie  same  form ;  but,  what  is  more  common, 
by  slow  degrees  the  mind  becomes  more  and  more  enfeebled 
till  at  length  its  powers  are  irretrievably  lost  in  the  ruin  of 
complete  dementia. 

Relation   of    various    Diseases    and    Functional 

Disorders   to   Insanity In  susceptible  persons  certain 

states  of  the  system,  both  physiological  and  pathological,  are 
sometimes  the  immediate  causes  of  insanity,  particularly  of 
mania;  and  in  many  cases  they  also  impart  a  distinctive 
character  to  the  mental  symptoms.  Thus  there  is  an  hys- 
terical mania  in  which  the  strange  imaginations  and  peculiar 
deceptions  characteristic  of  hysteria  are  associated  with  ex- 
citement, slight  incoiierence,  and  erotic  displays,  as  well  as 
generally  with  some  of  the  physical  symptoms  of  the  disease, 
such  as  the  passing  of  large  quantities  of  pale  urine,  and  the 
"  globus  hystericus."  This  form  would  seem  to  be  frequently 
dependent  on  irregularities  in  menstruation. 

At  the  establishment  of  the  menstrual  function  excitement 
with  delusions  and  a  disposition  to  impulsive  violence  may 
appear,  constituting  the  "  mania  of  puberty."  This  genei-ally 
passes  away  in  a  few  days  or  weeks,  and  seldom  continues 
after  menstruation  is  regular.  At  the  same  period  of  life,  in 
both  sexes,  instead  of  mania  a  moral  perversity  occasionally 
arises,  manifesting  itself  by  a  suddenly  acquired  disposition 
to  lying,  cheating,  stealing,  and  the  like — this  state  being 
the  result  of  disease,  tliough  very  often  not  so  considered. 
It  is  much  more  likely  'to  be  of  long  duration  than  the 
maniacal  condition,  and  too  often  gradually  involves  the  mind 
generally,  passing  ultimately  into  incurable  insanity. 

Disorder  of  the  Uterus  and  Ovaries,  at  any  time  during 
the  years  of  their  functional  activity,  especially  when  there 


230  INSANITY. 

is  amenorrhoca,  is  not  an  uncommon  cause  of  other  varieties 
of  insanity.  The  distinctive  delusions  that  spring  up  tlien 
have  often  reference  to  these  organs  or  to  tiieir  functions  : 
thus  the  sufferers  may  fancy  that  they  give  birtli  to  children, 
or  tliat  their  persons  are  violated  while  asleep.  Nympho- 
mania may  arise  from  the  same  source  ;  the  particuhu*  feature 
in  it  being  a  disj)Osition  on  the  part  of  the  })atient  to  make 
indecent  advances  to  the  other  sex,  and  even  to  make  shame- 
ful exposure  of  the  person.  A  distinction  has  been  drawn 
between  this  state,  which  is  regarded  as  due  to  the  general 
disturbance  of  the  nervous  system  from  a  peripheral  irritation 
in  the  sexual  organs,  and  that  named  Erotomania,  in  which 
the  organs  of  generation  are  apparently  healthy,  and  the 
morbid  action  is  believed  to  be  entirely  in  the  brain.  The 
mental  symptoms  are  really  alike  in  botli  ;  though  it  has 
been  held  by  some  that,  as  opposed  to  nymphomania,  the 
language  and  conduct  in  erotomania  are  pure,  and  do  not 
greatly  ti-ansgress  propriety.  In  the  male  sex  a  condition 
corresponding  in  the  cliaracter  of  the  acts  and  in  the  general 
jjsychical  features  is  known  as  Satyriasis.  It  is,  however,  to 
be  borne  in  mind  that  delusions  connected  with  the  organs 
of  generation  in  both  sexes  may  exist  with  perfect  propriety 
of  conduct,  and  also  that  amenorrhoea  is  a  common  symptom 
in  insanity  due  to  other  causes. 

Jt  the  close  of  men  st  mat  ion  one  of  the  many  troubles  that 
are  a|)t  to  arise  is  mental  disorder.  It  occasionally  assumes 
a  maniacal  character,  but  much  more  frequently  the  form  is 
melancholia,  with  delusions  and  a  disposition  to  suicide.  It 
has  been  named  "  climacteric  insanity." 

It  is  thought  by  some  that  excessive  venereal  indidc/eiicp, 
especially  in  the  newly  married,  may  suffice  to  overthrow  the 
mental  powers  in  susceptible  persons,  inducing  what  has  been 
designated  sexual  mania  ;  but  other  direct  causes  probably 
always  combine  with  it  in  the  production  of  the  insanity,  and 
there  is  notliing  distinctive  in  the  symptoms. 

The  vice  of  masturhation,  in  both  sexes,  sometimes  induces 
an  inti-actable  form  of  mental  derangement.  Early  symptoms 
springing  from  the  vile  habit  are  an  unwonted  shyness  and 
an  evasive  look,  irresolution  of  character,  and  a  disposition 
to  be  alone.  By-and-by  a  general  feeling  of  fear  and  suspi- 
cion of  others  arises,  with  sulkiness  of  temper;  then  come 
hallucinations,  such  as  that  the  victims  are  acted  on  through 
the  walls  by  electricity,  that  their  food  is  poisoned,  that  they 
are  tormented  by  evil  spirits,  &c.  ;  great  religious  fervor  is 


PUERPERAL    MANIA.  231 

common,  especially  in  women.  In  most  cases  the  intellect 
gradually  becomes  weak,  as  is  obvious  by  the  obtuse  expres- 
sion, and  after  an  indefinite  [)eriod  the  unfortunates  sink  into 
dementia.  General  nervous  symptoms,  such  as  palpitations 
and  feeling  of  sinking  at  the  heart,  are  usually  associated 
from  the  beginning  with  the  psychical  disturbance.  Should 
the  masturbation  be  stopped  before  the  intellect  is  much  im- 
paired, mental  health  may  be  restored;  but  once  insanity  has 
been  distinctly  established,  recovery  is  the  exception  rather 
than  the  rule,  as  the  vice  is  then  seldom  mastered. 

The  influence  exerted  on  the  mind  of  woman  by  the  sexual 
system  is  evinced  in  other  ways  than  those  mentioned.  The 
majority  of  women  are  more  susceptible  and  impressible,  and 
are  sometimes  very  irritable,  during  the  flow  of  the  menses. 
During  healthy  pregnancy^  also,  cravings  for  extraordinary 
articles  of  diet  are  very  common.  These  are  usually  inno- 
cent enough,  but  not  always,  as  when  a  woman,  overcome 
by  the  sight  of  the  brawny  arm  of  a  baker  who  worked  oppo- 
site her  dwelling,  compelled  her  husband  to  offer  him  money 
to  allow  her  to  take  "  one  bite"  out  of  it. 

Mental  disease  occasionally  a[)pears  during  utero-gestation, 
and  is  a[)i)arently  dependent  on  it ;  this  is  known  as  the  in- 
sanity of  pregnancy.  It  is  not  common,  and  is  more  prone 
to  occur  at  a  late  than  an  early  period  of  gestation.  Though 
mania  and  monomania  are  both  met  with,  melancholia  is  the 
usual  form,  refusal  of  food  and  a  disposition  to  suicide  being 
sometimes  marked  features.  The  majority  of  such  patients 
recover  soon  after  delivery,  but  a  large  proportion  continue 
insane. 

In  severe  labor,  during  the  passage  of  the  head  through  the 
OS  internum,  and  also  through  the  vaginal  orifice,  it  occa- 
sionally happens  that  the  patient  falls  into  a  state  of  semi- 
conscious delirium,  lasting  for  a  few  minutes.  The  writer 
has  seen  a  mild  attack  of  mania  arise  during  severe  labor 
i-esulting  from  contracted  pelvis,  which  passed  away  in  two 
days  after  delivery.     This  is  a  rare  event. 

The  most  important  of  all  this  group  of  disorders  is  that 
which  occurs  within  two  or  three  weeks  after  delivery,  and 
bears  the  name  of  Puerperal  mania.  The  fourth  or  fifth  day 
is  the  most  common  time  for  the  appearance  of  the  symp- 
toms, though  it  may  be  at  an  earlier  as  well  as  at  a  later 
period.  Sometimes  the  attack  is  very  sudden,  but  generally 
for  a  day  or  two  previously  the  patients  are  unusually  excit- 
able, sleep  but  little,  complain  of  pain  and  a  feeling  of  con- 


232  INSANITY. 

striction  in  the  head,  and  have  often  optical  tronldes,  such  as 
flashes  of  light  and  double  vision.  The  pulse  is  also  quick 
and  the  skin  may  be  hot.  When  the  insanity  is  fully  de- 
veloped the  symptoms  both  physical  and  mental  are  all  of  an 
a^ute  type,  and  the  condition  may  even  amount  to  delirious 
mania;  but,  fortunately,  this  is  somewliat  exceptional.  It  is 
a  feature  of  the  psychical  state  that  the  language  used  is  often 
filthy  and  obscene.  Aversion  to  husband  and  baby  are  com- 
mon, but  by  no  means  constant,  symptoms.  Under  the  influ- 
ence of  this  feeling,  mothers  have  in  many  instances  destro3re(i 
their  infants.  Cases  are  also  met  with,  l^eginning  within  a 
■week  after  childbirth,  in  which  the  condition  would  be  more 
correctly  designated  acute  melancholia  than  acute  mania. 
Early  in  the  disease,  as  a  rule,  both  the  lochial  discbarge  and 
the  mammary  secretion  are  arrested ;  but  in  mild  cases  the 
latter,  and  even  both,  may  continue  to  flow,  thoiigh  in  reduced 
quantity.  Occasionally  the  urine  is  found  to  be  albuminous. 
It  is  well  to  remember  that  there  is  also  sometimes  metritis 
or  endo-metritis.  as  these  are  apt  to  be  overlooked  through 
the  greater  prominence  of  the  mental  s}Tiiptoms. 

There  is  yet  another  important  variety  connected  Avith  the 
puerperal  state — the  uuanity  of  lactation.  It  occurs  after 
some  months'  nursing,  or  immediately  after  the  weaning  of 
the  infant,  and  is  due  to  the  drain,  through  the  mammary 
glands,  having  proved  too  much  for  a  feeble  or  susceptible 
frame.  As  might  be  expected,  the  patients  are  weak  and 
usually  anzemic.  Melancholia  is  the  type  of  disorder  that  is 
most  frequently  developed,  but  other  forms  are  occasionally 
seen.  In  this  variety  also,  a  disposition  to  destroy  the  infant 
is  not  uncommon ;  besides  this,  a  tendency  to  suicide  is  some- 
times manifested.  Ex-ojjhthalmic  goitre  and  functional  car- 
diac murmur  have  been  noticed  in  a  few  cases,  particularly 
where  the  mental  derangement  presented  maniacal  features. 

Alcoholic  Insanity As  already  stated,  .''  transitory  mania 

may  be  at  least  directly  induced  by  alcohol ;  but  besides  this 
and  the  much  more  common  disease,  Delirium  tremens  (see 
p.  199),  there  are  other  disorders  resulting  from  the  same 
powerftil  agent,  which  have  yet  to  be  noticed.  (1)  Habits 
of  intttsdcation,  along  with  the  ordinary  symptoms  of  chronic 
alcoholism,  often  induce  a  state  of  mind  characterized  by 
gloomy  suspicion  and  hallucinations  of  hearing.  This  con- 
dition has  prompted  to  homicide  as  well  as  to  suicide  in  a 
number  of  cases.  (2)  Excesses  in  alcohol  may  cause  mania 
or  melancholia  of  an  ordinary  acute  kind,  except  tliat  the 


ALCOHOLIC    AND    STPHTLTTIC    INSANITY.  233 

delusions  partake  of  the  delirium  tremens  character,  and  that 
the  attacks  themselves  are  of  shorter  duration.  Thoujjli 
cases  of  this  kind  are  occasionally  seen,  they  must  be  regarded 
as  rare.  (3)  Progressive  dementia,  accompanied  by  a  form 
of  general  paralysis,  is  a  rather  common  result  of  prolonged 
drunken  habits.  It  not  infrequently  occurs  in  women  who 
have  been  long  addicted  to  secret  tippling.  The  symptoms 
closely  resemble  those  of  ordinary  general  paralysis,  and  in 
some  cases  the  disorders  can  scarcely  l>e  distinguished  from 
each  other.  The  diagnosis  will  be  considered  in  connection 
with  general  paralysis.  (4)  There  remains  the  condition 
known  as  dipsomania  or  oinomania.  The  craving  for  drink 
in  this  state  is  insatiable,  and  no  consideration  whatever 
deters  the  victim  from  seeking  its  gratification.  Tiiree 
varieties  have  been  distinguished — the  acute,  the  chronic, 
and  the  periodic.  The  acute,  which  is  rare,  has  been  no- 
ticed after  hemorrhage  in  the  puerperal  state,  in  recovery 
from  fevers,  after  excessive  venereal  indulgences,  and  in 
some  forms  of  dyspepsia.  It  often  ])asses  away  in  a  few  days, 
and  shows  no  disposition  to  return.  The  chronic  is  the  form 
that  exists  in  the  habitual  drunkard.  In  him  the  craving 
for  alcoholic  stimulants  is  constant,  and  is  often  strongest  in 
the  morning.  He  experiences  a  sensation  of  sinking  at  the 
stomach,  with  a  feeling  of  mental  depression  amounting  even 
to  misery  when  not  under  their  influence.  Great  moral  de- 
pravity is  generally  a  marked  feature  of  character;  and  the 
writer  has  observed  that  in  women  this  is  usually  associated 
with  much  pretence  or  show  of  religion.  The  periodic 
variety  is  not  common.  It  occurs  in  pai'oxysms  of  exceeding 
severity,  ordinarily  with  intervals  of  some  months  between 
them.  All  these  varieties,  but  particularly  the  last  one,  are 
not  infrequently  the  outcome  of  the  •'  insane  temperament." 

The  poison  of  syphilis  in  the  constitution  may  give  rise  to 
different  forms  of  associated  disorder  of  the  brain  and  mind. 
Thus,  after  a  prodromal  period  of  irritability,  slowness  of 
mental  action,  and  occasional  confusion  of  ideas,  accom- 
panied by  shooting  pains  in  the  limbs  and  numbness  of  the 
head,  there  may  be  one  or  more  convulsive  fits,  followed  by 
mania  or  melancholia ;  or  instead  of  either  of  these  forms  of 
mental  derangement,  the  symptoms  mentioned  may  be  suc- 
ceeded by  a  hysterical  condition  which  rapidly  declines  into 
dementia  more  or  less  complete.  vSometimes  the  premonitory 
stage  is  succeeded  by. a  state  which  bears  considerable  like- 
ness  to  general  paralysis.     Tliere   mav  even   be   grandiose 

20* 


234  INSANITY. 

delusions  likewise,  though  this  is  not  common.  The  defects 
in  articulation  and  the  paresis  of  the  voluntary  muscles  gene- 
rally are  very  similar  in  both  cases.  In  the  syphilitic  form 
there  is  both  greater  rapidity  and  irregularity  in  the  progress 
of  the  symptoms.  Tlie  sensory  phenomena  are  likewise 
much  more  marked,  such  as  pains  in  the  limbs,  numbness, 
and  formication  ;  and  these,  as  well  as  the  motor  symptoms, 
are  more  apt  to  be  unilateral  at  an  early  stage  of  the  disease. 
The  retinae  are  not  so  uniformly  affected  :  and  should  tiiere 
be  irregularity  of  the  pupils,  it  wdll  probably  be  found  that 
some  of  the  ocular  muscles  are  also  paralyzed.  The  con- 
vulsive seizures  are  more  disposed  to  be  partial,  both  as 
regards  the  implication  of  consciousness  and  the  muscles  in- 
volved, than  in  the  case  of  general  paralysis,  and  the  attacks 
are  also  more  frequently  followed  by  paralysis  of  the  con- 
vulsed members;  this  may  or  may  not  be  persistent.  The 
evidences  of  constitutional  syphilis  in  nodes,  enlarged  glands, 
cutaneous  eruptions,  &c.,  with  a  history  of  contagion,  will  of 
course  materially  aid  the  diagnosis. 

Besides  a  real  there  is  also  a  spurious  syphilitic  insanity, 
which  bears  the  name  of  SyphilopJiobia.  The  distinctive 
feature  of  tliis  disorder  is  an  intense  fear  in  the  mind  of  the 
sufferer  that  syphilis  has  been  acquired,  every  trifling  papule 
being  regarded  as  convincing  evidence  of  its  presence.  In 
other  resjject-s  the  mental  state  is  that  of  acute  melancholia. 
It  is  most  frequently  met  with  in  persons  of  high  moral  tone 
wdio  have  once  or  twice  fallen  into  irregularity  of  conduct. 

Epileptic  Insanity When    epilepsy   has   continued   for 

some  years  it  induces  mental  defect,  and  this  may  occur 
much  sooner  if  the  fits  are  frequent,  but  if  they  are  at  long 
intervals  the  mind  may  remain  unaffected.  In  some  cases 
\k\Q  petit  mal  would  appear  to  exert  a  more  baneful  influence 
on  the  mental  powers  than  the  full  convulsive  seizure  ;  but 
tliis,  though  asserted  by  some,  is  not  always  the  case,  as  the 
writer  has  seen  patients  subject  to  the  latter  form  in  whom 
dementia  rapidly  su})ervened,  and  others  who  had  suffered 
from  epileptic  vertigo  for  years,  at  short  intervals,  and  still 
retained  considerable  mental  vigor.  Irritability  of  temper 
and  w^eakness  of  memory  are  the  flrst  indications  of  the  mind 
being  involved,  but  in  course  of  time  all  its  powers  are  im- 
plicated, and  ultimately  the  wreck  is  complete.  But  instead 
of  an  uniform,  progressi\  e  degeneration,  it  often  happens  that, 
after  a  single  seizure  or  a  number  in  succession,  an  acute 
maniacal  attack  occurs,  in  which  there   is  generally  mani- 


EPILEPTIC    MANIA.  235 

fested  a  disposition  to  violence,  and  occasionally  also  to- 
suicide  in  the  same  patient.  The  mania  may  pass  away  in 
a  few  minutes  or  in  an  hour  or  two,  and  in  any  case  seldom 
lasts  longer  than  four  or  five  days,  though  it  is  apt  to  return 
on  the  recurrence  of  the  fits.  The  last  feature,  however,  is 
very  irregular,  and  in  illustration,  the  writer  may  allude  to 
a  patient  under  his  care  who  had  an  attack  of  epileptic  mania 
about  five  years  ago,  and  has  continued  free  from  it  since, 
while  there  has  been  no  abatement  of  the  convulsive  seizures. 
Though  the  mental  disorders  generally  follows  the  convul- 
sions, it  occasionally  precedes  them,  and  in  some  cases  would 
seem  to  take  their  place,  the  entire  paroxysm  being  appa- 
rently mental.  In  some  instances  epileptics  fall  into  an 
automatic  state  without  having  had  a  convulsive  attack,  and 
then  perform  actions  which,  though  usually  irregular  and 
destructive,  may  be  definite  and  correct  in  themselves,  but 
only  wrong  as  to  time  or  place — the  p'atients  being  quite 
unconscious,  and  incredulous  when  told  of  their  conduct  on 
their  recoveiy.  This  state  is  generally  very  brief,  lasting 
only  for  seconds  or  minutes,  but  it  may  continue  for  half  an 
hour,  seldom  longer. 

The  poison  of  rheumatism  and  gout  in  the  system  may 
induce  mental  disorder  which  sometimes  amounts  to  insanity. 
Such  attacks  are  often  of  a  metastatic  character,  the  joint 
affection  being  in  abeyance  during  the  continuance  of  the 
mania,  which  is  the  usual  form  of  derangement  in  these 
circumstances.  The  attack  commonly  passes  away  within 
three  or  four  weeks.  A  similar  event  may  occur  in  the 
course  of  asthma.  For  example,  a  person  who  had  been  a 
martyr  to  the  spasmodic  form  of  the  disease  for  nearly 
twenty  years,  rather  suddenly  became  maniacal ;  the  asthma 
then  entirely  disappeared,  and  did  not  trouble  her  during 
the  six  weeks  that  the  insanity  lasted ;  but  when  the  latter 
subsided,  the  asthma  returned  in  all  its  former  oppressive- 
ness. The  writer  has  also  seen  the  poison  of  lead  induce 
an  attack  of  mental  derangement,  which  continued  for  a  few 
days  ;  there  were  also  convulsions  in  the  case ;  the  character- 
istic blue  line  on  the  gums  was  present. 

Phthisical  Insanity In  the  later  stages  of  phthisis  pul- 

monalis  mania  is  occasional  developed.  The  symptoms  are 
generally  very  acute,  even  attaining  the  severity  of  those  of 
delirious  mania  ;  the  attack  often  terminates  in  fatal  exhaus- 
tion. In  an  earlier  stage  of  the  same  disease,  or  of  general 
tuberculosis,  Dr.  Cloustou    has    pointed  out   that  a  morbid 


236  INSANITY. 

■mental  condition  of  a  flifFerent  character  is  sometimes  pre- 
sent. It  is  characterized  by  unfounded  suspicion  and  irrita- 
bility, with  occasional  bursts  of  excitement  or  fits  of  depres- 
sion. This  mental  state  is,  however,  not  so  common  as  an 
opposite  one  in  tubercular  disease  of  the  lungs,  in  which  the 
patients  are  sanguine  and  unduly  hopeful,  even  when  their 
illness  is  going  on  to  a  fatal  issue.  But  the  psychical  con- 
dition in  the  latter  case  is  not  insanity. 

The  feeling  of  sinking  and  general  discomfort  experienced 
by  those  habituated  to  the  use  of  opium,  in  whatever  form 
and  way  it  be  taken,  when  they  are  not  under  its  influence, 
occasionally  attains  to  such  a  degree  of  intensity  that  the 
condition  may  even  amount  to  insanity.  The  unfortunate 
sufferers  who  have  arrived  at  this  stage,  after  the  effect  of 
the  drug  has  died  away,  are  wretched,  miserable,  and  may 
even  be  suicidally  disjiosed.  The  writer  has  known  it  neces- 
sary to  commit  such  an  one  to  an  asylum  ;  but  this  is  quite 
exceptional. 

The  excitability  which  is  an  ordinary  symptom  of  Graves's 
or  Basedow's  disease  (Exophthalmic  goitre),  may  increase 
and  be  accompanied  by  incoherence  and  violence,  so  that 
mania  is  established.  The  attack  commonly  subsides  in  a 
few  days. 

Tape-worm  in  tlie  intestinal  canal  may  induce  mania 
through  the  action  of  the  peripheral  irritation  on  the  brain, 
just  as  it  occasionally  gives  rise  to  epilepsy. 

Blows  or  falls  on  the  head  are  not  infrequently  followed 
by  insanity.  The  form  varies :  mania  and  dementia  are 
both  met  with,  as  also  a  combination  of  the  two.  The  con- 
dition is  hopeful  or  otherwise,  according  to  the  amount  of 
injury  sustained  by  the  brain. 

When  distinct  insanity  is  produced  by  sunstrohe,  or  follows 
typhus  fever  or  other  of  the  exanthemata,  although  mania 
may  be  the  primary  character,  dementia  generally  soon 
ensues  ;  or  the  insanity  may  be  of  this  form  from  the  first. 
The  prognosis  in  these  cases  is  generally  unfavorable.  But 
this  is  to  be  distinguished  from  a  condition  of  mental  excite- 
ment of  moderate  severity,  accompanied  by  hallucinations  of 
hearing  and  sight,  which  occasionally  arises  somewhat  sud- 
denly in  an  advanced  stage  of  these  diseases,  and  also  in 
pneumonia,  but  usually  passes  away  in  a  day  or  two,  or  even 
sooner.  This  has  been  lately  described  as  a  form  of  insanity ; 
but  observation  of  such  cases  would  rather  lead  the  writer 
to  designate  it  as  an  acute  form  of  delirium,  symptomatic  of 


SUNSTROKE —  FEVERS  —  IMPULSIVE.  -  237 

the  associated  disease,  though  not  ahvavs  of  a  state  of  col- 
lapse, as  was  believed  by  Di-.  H.  Weber,  who  first  directed 
attention  to  tliis  variety  of  mental  disorder. 

The  catalogue  of  physical  diseases  or  causes,  on  which 
insanity  may  be  more  or  less  dependent,  has  not  yet  been 
exhausted.  In  fact  it  would  seem  that  a  morbid  condition 
of  any  organ,  in  persons  of  weak,  susceptible,  nervous  sys- 
tems, may  so  disturb  the  functions  of  the  brain  that  mental 
derangement  may  be  the  result.  Thus  it  has  been  developed 
in  connection  with  intestinal,  hepatic,  and  vesical  diseases. 
There  is  little  uniformity  in  the  symptoms  of  the  insanity 
which  arises  in  this  way  ;  and  it  would  rather  appear  that 
the  character  of  the  mental  disturbance  is  more  dependent 
on  the  general  condition  of  the  system  as  to  strength  or 
weakness,  and  on  the  nature  of  the  hereditary  bias  which 
so  commonly  exists,  than  on  the  special  organ  whose  morbid 
state  may  have  been  the  exciting  cause  of  the  cerebro-mental 
disorder.  At  tlie  same  time  it  may  be  said  generally  that 
disease  in  the  abdominal  organs,  and  especially  in  the  liver, 
is  more  apt  to  be  associated  with  melancholia  than  with  any 
other  form.  But  in  considering  the  association  of  disease  in 
tliese  organs  with  insanity  it  is  always  to  be  borne  in  mind 
that  this  may  be  altogether  accidental,  or  that  their  morbid 
state  may  be  due  to  that  impaired  nutrition  of  the  central 
nervous  system  on  which  the  insanity  itself  depends. 

Impulsive  Insanity. — A  tendency  to  act  under  insane  im- 
pulses is  a  feature  of  the  acute  forms  of  mania  and  melan- 
cholia, particularly  the  former.  Besides  this,  however,  there 
are  varieties  in  which  this  disposition  is  the  chief,  and  occa- 
sionally almost  the  only  evidence  of  mental  derangement. 
Generally  there  is  only  one  kind  of  impulse  in  tlie  same 
patient,  but  there  may  be  more  than  one,  and  the  one  may 
alternate  with  the  other.  The  suicidal  and  the  homicidal 
are  the  most  common  and  the  most  important,  and  bear  the 
names  of  Suicidal  and  Homicidal  mania,  although  this  last 
form  is  rare,  and  recently  its  very  existence  has  been  ques- 
tioned by  some  authoi-ities. 

Similar  morbid  impulses  to  steal  and  to  set  fire  to  houses, 
&c.,  are  known  respectively  as  Kleptomania  and  Pyromania. 
But  homicidal  and  other  criminal  acts  are  much  more  fre- 
quently the  result  of  delusions,  and  more  particularly  of 
"  voices"  that  may  seem  to  the  victims  to  oome  from  Heaven, 
requiring  implicit  obedience  from  them  as  a  sacred  duty. 

The  impulsive  tendency  is  not  infrequently  manifested  in 


238  INSANITY. 

persons  respecting  whom  no  snspicion  of  mental  defect  is 
entertained  by  others,  in  prompting  to  break  large  slieets  of 
glass,  to  interrupt  public  speakers  in  their  addresses,  and  to 
other  actions  which  the  patients  know  full  well  to  be  wrong, 
and  struggle  against  with  all  their  might,  and  fortunately 
almost  always  successfully.  In  some  who  were  troubled  in 
this  way  the  writer  has  found  other  indications  of  derange- 
ment in  the  nervous  system — one  which  was  much  com- 
plained of  being  a  "  springy"  feeling  in  the  feet,  as  if  they 
were  made  of  india-rubber.  This  sensation  was  experienced 
every  few  steps  in  walking,  and  when  severe  passed  up  to 
the  head,  producing  a  giddy  feeling.  Another  troublesome 
symptom  was  involuntary  starting  of  the  limbs  in  going  to 
sleep.  In  all  these  patients  the  cause  appeared  to  be  mental 
strain. 

Sometimes  the  moral  powers  of  the  mind  are  affected  in  a 
marked  manner,  while  the  intellectual  are  but  little  dis- 
turbed. This  condition  has  been  called  Moral  insanity. 
Those  in  whom  it  is  seen  have  usually  a  strong  hereditary 
bias  towards  mental  disorder,  and  may  have  previously  suf- 
fered from  it  in  one  of  its  more  complete  forms — particularly 
mania.  Pure  cases  of  this  variety  are  rare:  still  they  are 
met  with  occasionally.  The  symptoms  are  lying,  stealing, 
cheating,  mischief-making  of  all  kinds,  and  a  disposition  to 
violence — these  being  opposed  to  the  patient's  former  charac- 
ter. In  one  characteristic  case,  long  under  observation,  be- 
sides the  state  just  described,  there  was  further  evidence  of 
morbid  change  in  the  brain  in  partial  hemiplegia.  This 
designation — Moral  insanity — is  objectionable,  and  should 
be  avoided  by  medical  witnesses  in  courts  of  law :  if  required 
to  define  the  condition,  it  is  better  to  speak  of  "partial  in- 
sanity." 

Melancholia  stands  next  in  importance  to  mania  as  a 
leading  form  of  insanity.  It  is  often  met  with  as  Simple 
Melancholy,  without  delusion  or  distinct  intellectual  derange- 
ment of  any  kind.  The  patient  is  aware,  and  admits  that 
there  is  no  real  cause  for  the  mental  depression,  but  is  quite 
unable  to  shake  it  off.  A  sense  of  the  ludicrous  may  exist 
along  with  this  habitual  state  of  feeling.  A  disposition  to 
suicide  is  frequently  present.  It  will  usually  be  found  that 
the  general  health  is  weak;  and  in  women  there  is  often 
anaemia  and  frequently  also  leucorrhoea. 

Hypochondriasis  passes  into  melancholia  when  the  more 
or  less  imaginary  troubles  that  affect  the  patient  amount  to 


MELANCHOLIA.  239 

actual  delusion,  out  of  which  he  cannot  be  reasoned.  In 
illustration  of  this,  a  patient  complained  for  a  long  time  of 
uneasiness,  and  sometimes  of  severe  pains  in  the  abdomen, 
for  which  there  was  no  very  obvious  cause ;  then  she  became 
miserable,  and  declared  that  the  devil  himself  was  in  her 
belly.  Her  first  condition  could  not  be  pronounced  to  be 
insanity,  but  when  the  delusion  arose,  the  proof  of  it  was 
clear.  In  hypochondriasis  the  depression  of  feeling  is  seldom 
so  great  as  in  melancholia;  and  in  the  latter,  besides  delu- 
sions, a  disposition  to  suicide  is  more  marked  than  in  the 
former. 

Acute  melancholia  may  be  suddenly  caused  by  a  severe  - 
mental  shock,  but  it  is  much  more  frequently  preceded  by  a 
long  preliminary  stage  of  depression.  When  the  disorder  is 
fully  developed  the  unhappy  feeling  may  attain  to  one  of 
despair.  The  wretched  sufferer  may  utter  loud  lamenta- 
tions, tear  his  hair,  strike  his  breast,  and  even  make  des- 
perate attempts  at  self-destruction.  It  is  seldom,  however, 
that  the  condition  is  so  bad  as  this;  but  there  are  all  degrees 
between  simple  melancholy  and  the  state  just  described. 
The  attitude  and  the  expression  betoken  the  mental  frame. 
In  some,  the  arms  hang  heavily  by  the  side,  the  eyes  are 
turned  downwards  towards  one  point,  and  are  almost  statue- 
like in  the  fixity  of  their  gaze,  and  the  angles  of  the  mouth 
are  depressed ;  or — the  morbid  feeling  being  more  acute — 
the  hands  are  clenched,  the  features  are  tense,  and  the  suf- 
ferer moves  about  in  restless  agitation.  The  latter  variety 
is  less  common  than  the  former.  Notwithstanding  their 
misery,  melancholies  seldom  shed  tears;  their  sorrow  is  too 
deep  for  that.  In  most  cases  they  are  decidedly  worse  in 
the  morning,  just  after  awaking  from  sleep.  Though  in  gen- 
eral sleep  is  broken  and  much  disturbed  by  unhappy  dreams, 
it  is  by  no  means  so  deficient  in  amount  as  is  the  case  in 
acute  mania.  The  pulse  is  weak  and  not  accelerated ;  the 
skin  is  clammy  and  cold,  and  the  lips  have  a  purplish  tinge ; 
the  tongue  is  apt  to  be  furred,  and  is  sometimes  indented  at 
the  edges;  the  bowels  are  generally  constipated,  and  the 
breath  offensive,  and  the  stools  are  occasionally  deficient  in 
bile.  There  is  usually  amenorrhcea  in  women.  Refusal  of 
food  is  common,  and  may  arise  from  delusion,  from  suicidal 
intent,  or  from  real  derangement  of  the  digestive  organs. 
Precordial  anxiety  is  not  uncommon :  and  in  some  cases  of 
intermittent  melancholia  the  paroxysm  begins  with  this  sen- 
sation, which  seems  to  the  patient  to  extend  upwards  to  the 


240  INSANITY. 

liead,  and  then  tlie  gloom  and  mental  pain  are  experienced. 
In  some  caset? — I'ortunately  rather  rare — the  physical  symp- 
toms correspond  closely  with  those  of  delirious  mania,  and, 
as  in  it  also,  the  mortality  is  high. 

There  is  a  form  of  melancholia  known  as  Melancholy  with 
stupor,  or  Melancholia  attonita.  It  has  two  varieties,  de- 
pending on  whether  the  element  of  stupor  or  that  of  profound 
melancholy  })i'evails.  Tiie  symptoms  are  much  alike  in  both. 
The  patients  stand  in  the  one  position,  or  continue  the  same 
motion,  heedless  of  what  ])asses  around ;  they  require  to  be 
fed,  and  often  resist  artificial  feeding;  and  they  are  frequently 
'inattentive  to  the  calls  of  nature.  The  circulation  is  languid 
and  the  skin  is  cold  and  bluish.  The  varieties  are  best  dis- 
tinguished by  the  aspect.  In  the  mehmcholic  the  features 
are  tense,  and  the  countenance,  as  a  whole,  betrays  fear  or 
anguish  so  deep  that  the  mental  powers  are  overwhelmed  ; 
whereas  in  the  other,  while  a  certain  amount  of  depression 
is  evident,  stupidity  predominates  in  the  expression.  It 
often  happens  in  this  form  of  mental  disorder  that  serious 
disease  in  other  organs,  particularly  the  lungs,  may  be  insidi- 
ously progi'essing  though  manifesting  very  indistinct  symp- 
toms. 

Acute  melancholia,  though  often  recovered  from  in  a  few 
weeks  or  months,  may  become  chronic,  or  the  clironic  form 
may  supervene  on  acute  mania,  in  wdiich  case  there  is  usu- 
ally more  or  less  dementia  along  with  it.  Whatever  its  ori- 
gin, melancholia,  if  confirmed,  has  a  tendency  to  pass  into 
dementia,  though  that  frequently  does  not  occur  for  many 
years.  The  chronic  forms  are  not  unfrequently  associated 
with  disease  in  one  or  other  of  the  abdominal  organs,  on 
which  they  may  be  partially  dependent.  The  ordinary  forms 
are  incident  to  middle  or  declinino;  life,  though  it  is  not  rare 
to  meet  with  them  in  young  people.  Melancholy  with  stupor 
on  the  other  hand,  is  much  more  a  disease  of  youth  than  of 
age. 

Circular  Insanity  {Folie  circulaire  of  the  French)  is 
a  form  in  which  mania  and  melancholia  alternate,  sometimes 
with  intervals  of  a  few  days,  or  a  week  or  two,  of  apparent 
sanity.  The  alternating  condition  often  partakes  more  of  de- 
mentia than  of  melancholia.     It  is  very  frequently  incurable. 

Monomania  is  generally  used  to  signify  partial  insanity 
of  the  intellect.  The  term  is  misleading  if  it  be  regarded  as 
meaning  mental  unsoundness  on  one  subject,  the  judgment 
and  the  emotional  powers  in  other  respects  being  absolutely 


MONOMANIA — GENERAL    PARALYSIS.  211 

free.  However  limited  the  delusive  idea,  the  natural  tone  of 
the  mind  is  always  altered, — elevated  or  depressed,  expanded 
or  contracted, — and  there  is  also  a  morbid  exaggeration  of 
self-feeling.  At  the  same  time  cases  are  not  rare  where  the 
intellect  is  wonderfully  sound  and  vigorous  outside  the  sphere 
of  morbid  ideas.  Thus,  two  cousins,  men  about  forty  years 
of  age,  came  under  notice  at  the  same  time,  the  one  of  whom 
fancied  that  his  penis  was  once,  somehow,  tampered  with  by 
his  fellow-workmen,  and  also  that  on  several  occasions,  with- 
out his  consent,  he  had  been  acted  on  by  electrical  agents  ; 
whilst  the  other  declared  that  he  himself  was  "  a  little  Christ," 
On  all  other  subjects  they  were  apparently  sensible,  intelli- 
gent men,  with  whom  one  might  talk  for  hours  without  dis- 
covering their  morbid  fancies,  unless  one  had  a  clue  to  then 
previously.  However,  the  unhealthy  state  of  feeling  above 
referred  to  was  obvious.  The  delusions  of  monomania  are  of 
endless  variety.  They  may  be  roughly  gi'ouped  according 
to  the  prevailing  morbid  sentiment,  which,  as  has  already 
been  said,  lies  at  the  root  and  precedes  formal  delusion.  One 
class,  in  which  there  is  exaltation  of  feeling,  is  characterized 
by  morbid  ideas  respecting  power,  wealth,  talents,  personal 
appearance,  &c.  In  another  class,  suspicion  being  the  pre- 
vailing sentiment,  the  patient  may  probably  imagine  that 
there  is  a  plot  against  his  life,  that  spies  dog  his  footsteps, 
and  that  his  food  is  drugged.  Prompted  by  such  fancies, 
lunatics  in  a  number  of  cases  have  killed  their  imaginary 
persecutors.  Hallucinations  and  illusions,  especially  those 
of  hearing,  besides  delusions  proper,  are  common.  They  are 
very  important  should  they  assume  the  form  of  "  voices" 
conveying  commands  to  the  patient,  and  particularly  should 
there  be  any  disposition  to  obey.  This,  as  previously  men- 
tioned, is  a  frequent  source  of  suicide  and  homicide  in  the 
insane. 

Monomania,  especially  when  accompanied  by  hallucina- 
tions of  hearing,  is  an  intractable  form  of  insanity.  Still, 
occasional  recoveries  do  take  place  after  it  has  lasted  for 
several  years.  In  most  cases,  as  time  passes,  additional 
delusions  spring  up,  and  the  morbid  circle  gradually  widens 
till  the  intellect  is  entirely  involved.  Then  there  is  also 
incoherence,  the  mental  degeneration  having  passed  into 
incurable  dementia.  The  general  bodily  health  during  this 
slowly  progressive  mental  decay  is  usually  very  good. 

General  Paralysis,  also  called  '"general  paresis,"  and 
sometimes  "  paralytic  dementia,"  is  a  very  important  and 
21 


242  INSANITY. 

a  very  fatal  form  of  insanity.  It  is  peculiarly  a  disease  of 
middle  life,  seldom  occurring  under  thirty  or  above  sixty 
years  of  age.  It  is  at  least  four  times  more  common  among 
men  than  among  women.  Its  ordinary  duration  is  from  two 
to  three  years ;  but  it  may  terminate  fatally  in  six  months, 
or  be  protracted  for  six  years  or  longer.  When  the  disease 
is  developed,  in  nine  cases  out  of  ten  there  is  exaltation  of 
feeling,  though  this  is  occasionally  preceded  by  a  brief  period 
of  depression ;  and  in  a  few  very  exceptional  cases  there  is 
melancholy  feeling  throughout  its  whole  course.  After  this 
brief  preliminary  stage  of  depression  has  passed  away,  if  it 
existed  at  all,  the  patient  becomes  restless  and  flighty  in  his 
manner,  and  impatient  of  control.  He  spends  his  money 
foolishly,  and  launches  forth  into  wild  speculations.  Then 
the  characteristic  delusions  arise.  He  asserts  he  is  worth 
millions  of  money,  is  as  strong  as  Samson,  and  is  King  of 
the  Universe :  any  or  all  of  these  or  similar  extravagant 
notions  may  be  entertained.  Even  in  this  stage,  the  defect- 
ive memory  and  the  inability  to  follow  out  any  subject  of 
thought,  reveal  the  enfeeblement  of  intellect ;  and  emotional 
weakness  may  also  be  evident  in  the  aspect,  and  the  ten- 
dency to  bursts  of  passion  if  in  any  way  opposed.  At  this 
period  there  is  also  sometimes  a  disposition  to  indulge  to 
excess  in  alcohol,  and  to  be  indecent  in  conduct  before  the 
opposite  sex  ;  occasionally  a  proclivity  to  steal  is  manifested. 
The  delusions  usually  persist  to  near  the  fatal  close,  or,  at 
least,  so  long  as  advancing  defect  in  articulation  permits  of 
their  being  recognized  ;  but  even  they  would  seem  sometimes 
to  be  involved  in  the  utter  wreck  of  mind  in  the  final  stage. 
In  the  earlier  period  of  the  disease,  maniacal  excitement, 
with  destructive  tendencies,  is  very  common. 

Indications  of  the  paralysis  appear  in  most  cases  shortly 
after  the  onset  of  the  psychical  disturbance.  Tlie  two  sets 
of  symptoms  may,  however,  occur  simultaneously,  and  the 
paralytic  may  even  precede  the  mental  disorder.  These 
indications  are  first  noticeable  in  tremor  of  the  upper  lip, 
especially  when  the  zygomatici  and  the  elevators  of  the  lips 
are  in  action.  Certain  movements  of  the  tongue  are  like- 
wise not  performed  with  their  natural  precision.  The  pa- 
tient has  thus  difficulty,  in  articulating  words  in  which  there 
ares  everal  labials  or  liquids — Tolerable,  February,  Consti- 
tutional— ^for  example.  The  defect  seems  a  thickness  or 
slight  stuttering,  like  that  of  a  person  in  the  first  stage  of 
drunkenness ;  and  it  may  only  be  observable  at  this  period 


DIAGNOSIS    OP    GENERAL    PARALYSIS.  243 

when  the  patient  is  under  emotion.  It  is  not  usually  till 
after  some  weeks  or  even  months  have  elapsed  that  the  mus- 
cles of  the  lower  extremities  are  involved.  Then  there  is 
observable  at  first  a  peculiar  cautiousness  of  gait,  with  slight 
uncertainty  and  unsteadiness,  most  distinct  when  about  to 
turn  after  walking  a  few  paces.  The  arms  are  often  late  of 
being  much  implicated,  but  ultimately  they  do  not  escape. 
As  the  disease  progresses,  the  articulation  becomes  more 
indistinct,  the  tongue  while  being  put  out  is  projected  in  a 
jerky  manner,  and  a  fibrillar  movement  is  observed  in  its 
substance.  All  the  muscles  of  the  face  are  involved,  and  a 
characteristic  hebetude  of  expression  is  acquired.  Though 
both  sides  are  generally  affected  pretty  equally,  the  paralysis 
occasionally  is  more  pronounced  in  the  muscles  of  the  one 
side  than  the  other.  When  the  disease  is  far  advanced,  the 
muscles  of  deglutition  and  respiration  participate  in  the  in- 
creasing ruin,  and  it  is  not  seldom  that  death  occurs  from 
choking  by  a  morsel  of  ordinary  food.  In  most  cases  after 
it  has  reached  its  middle  stage,  epileptiform  seizures  and 
attacks  of  cerebral  congestion  occur  occasionally.  The 
pupils  are  very  generally  unequal ;  in  some  they  are  minutely 
contracted  ;  in  exceptional  cases  they  are  normal.  There  is 
hyperiemia  of  the  retina  in  the  early  stage,  and  neuro- 
retinitis,  quickly  passing  into  atrophy,  when  the  distinctive 
symptoms  of  the  disease  are  obvious ;  there  are  not  many 
exceptions  to  this  rule.  Defect  in  cutaneous  sensibility  is 
not  very  marked  at  first,  but  later  its  existence  is  clear  ; 
local  hyperresthesife  may  co-exist  with  it.  The  muscular 
sense  is  also  impaired  ;  and  electric  contractility  suffers  at 
an  advanced  period.  When  the  disease  is  distinctly  pro- 
gressing, the  evening  temperature  is  often  from  2°  to  4°  F. 
above  the  normal.  Htematoma  auris  not  unfrequently  occurs 
along  with  the  more  acute  symptoms.  In  a  few  cases, 
during  the  course  of  the  disease,  there  are  remarkable  re- 
missions, extending  over  a  number  of  months,  and  these  may 
be  so  complete  that  a  cure  may  be  supposed  to  have  been 
effected ;  but  unfortunately,  with  scarcely  an  exception, 
there  is  a  relapse,  leading  ultimately  to  a  fatal  issue. 

In  private  practice  General  Paralysis  is  very  often  over- 
looked in  its  early  stage.  In  a  few  exceptional  cases  the 
diagnosis  is  difficult,  but  in  the  great  majority,  when  the 
symptoms  are  looked  at  together — for  no  one  by  itself  is 
pathognomonic — it  is  easy,  and  a  mistake  should  not  occur. 
The  following  are  the  leading  symptoms,  mentioned  in  their 


244  INSANITY. 

order  of  importance : — Difficulty  in  articulating  certain 
words,  and  tremor  of  the  upper  lip  ;  emotional  weakness 
with  exaltation  (it  may  be  necessary  to  contradict  the  pa- 
tient before  these  are  properly  manifested)  ;  grandiose  delu- 
sion ;  general  feebleness  of  judgment  and  memory  ;  unsteadi- 
ness of  gait ;  inequality  of  pupils  ;  liypera^mia  of  retina, 
followed  by  atrophy  of  optic  disk.  Sometimes  the  intense 
self-feeling,  as  Avell  as  the  exaltation,  come  out  most  dis- 
tinctly in  writing,  and  it  may  therefore  be  advisable  to  ask 
the  patient  to  write  his  views  on  any  subject  in  which  he 
may  seem  to  be  particularly  interested. 

The  disease  for  which  it  is  most  apt  to  be  mistaken  is  a 
form  of  paralytic  dementia  due  to  long-continued  excesses  in 
alcohol ;  and  certainly  it  is  occasionally  very  difficult  to  dis- 
tinguish between  them.  This  is  not  surprising  when  it  is 
remembered  that  habits  of  drimkenness  are  sometimes  asso- 
ciated with  over-indulgence  in  venery  in  the  production  of 
real  general  paralysis.  The  distinguishing  features  of  the 
alcoholic  variety  are : — Stupidity  with  depression  of  feeling, 
rather  than  emotional  exaltation  with  intellectual  weakness 
and  extravagant  delusions ;  belief  in  present  or  pjist  halluci- 
nations of  the  alcoholic  type  ;  no  inequality  or  other  abnor- 
mal state  of  pupils ;  defects  in  articulation  partaking  of  a 
drawl  as  well  as  of  a  stutter ;  absence  of  retinal  change  ex- 
cept congestion  at  first,  which  rapidly  subsides ;  the  whole 
aspect  one  of  obtuseness  rather  than  of  exaltation  combined 
with  feebleness.  Still,  cases  do  occur  now  and  again  when 
the  paralytic  and  mental  symptoms  are  very  much  alike  in 
both  forms,  and  there  may  be  nothing  but  a  history  ot 
habitual  drunkenness,  and  of  a  former  attack  or  attacks  of 
delirium  tremens,  with  normal  state  of  the  pupils  and  only 
slight  congestion  of  the  fundus  of  the  eye,  on  which  to  base 
a  rather  doubtful  diagnosis  of  alcoholic  dementia. 

Monomania  occasionally  l)ears  a  degree  of  resemblance  to 
general  paralysis  in  its  early  stage.  The  delusions  may  be 
equally  extravagant  in  both,  but  in  the  former  there  is  less 
variability  in  their  character ;  the  memory  is  good,  the 
judgment  in  other  respects  may  not  be  obviously  impaired, 
and  altogether  there  is  greater  mental  vigor.  Besides,  the 
paresis  of  the  muscles  of  articulation,  emotional  weakness, 
&c.,  are  not  present. 

Locomotor  ataxy  in  its  ordinary  form  can  scarcely  be  mis- 
taken for  the  disease  under  consideration.  But  the  patho- 
logical changes  in  the  cord  found  in  ataxv  would  seem  occa- 


DEMENTIA.  245 

sionally  to  extend  to  the  medulla  oblongatii  and  higher  parts 
of  the  brain,  inducing  defective  articulation  and  mental  dis- 
order. Delusions  of  grandeur  are  not  a  common  feature  of 
insanity  arising  thus. 

It  will  suffice  merely  to  mention  that  the  mental  and  phy- 
sical degradation,  which  are  often  found  in  epilepsy  of  long 
standing,  occasionally  bears  a  general  resemblance  to  a  some- 
Avhat  advanced  stage  of  general  paralysis,  in  which,  as 
already  stated,  epileptiform  seizures  are  common  ;  an  inquiry 
into  the  history,  besides  a  study  of  the  symptoms,  should  at 
once  establish  the  diagnosis. 

Dementia  is  usually  the  sequel  to  other  forms  of  mental 
disorder.  Mania  occasionally  passes  into  it  after  a  few- 
months,  but  this  is  not  usual  till  a  much  longer  time  has 
elapsed.  Melancholia  and  partial  intellectual  insanity,  as  a 
rule,  reach  dementia  at  a  considerably  later  period  than 
mania  does :  often  not  for  many  years.  The  condition 
ranges  in  degree  from  slight  enfeeblement,  characterized  by 
dulness  of  apprehension,  weakness  of  memory,  and  inability 
to  follow  out  a  subject ;  or  by  general  silliness  of  language 
and  conduct ;  to  complete  mental  disorganization,  in  which 
the  patients  are  unable  to  comprehend  the  simplest  ques- 
tions, and  require  all  their  wants  to  be  attended  to  like  an 
infant.  In  most  cases,  however,  even  when  the  intellect  is 
in  this  degraded  state,  dements  can  take  their  food  them- 
selves. When  the  psychical  ruin  is  less  complete,  but  still 
in  cases  where  there  is  great  incoherence  of  thought,  patients 
are  quite  able  to  follow  manual  occupations,  such  as  shoe- 
making  or  tailoring,  to  which  they  had  been  trained  previous 
to  their  insanity.  The  bodily  health  in  this  state  is  gener- 
ally good,  and  there  may  be  marked  obesity. 

In  dementia  there  may  usually  be  observed  traces  of  the 
particular  form  of  derangement  which  prevailed  at  the  de- 
parture from  mental  health.  Thus,  in  the  epileptic  variety, 
irritability  and  a  disposition  to  violence  are  marked  features ; 
in  the  general  pai-alytic  form  there  are  the  delusions  of 
grandeur ;  in  that  of  monomania  fragments  of  the  original 
delusions  are  often  observable  i  and  when  it  results  from 
mania  tliere  are  occasional  bursts  of  excitement  with  inco- 
herence and  fragmentary  delusions,  making  it  occasionally 
difficult  to  tell  whether  a  particular  case  ought  to  be  regarded 
as  chronic  mania  or  dementia.  The  vestiges  of  the  primary 
mental  disorder  are  not,  however,  traceable  in  the  last  stage 
except  in  the  epileptic  and  paralytic  varieties. 

21* 


246  INSANITY. 

Senile  dementia  is  particularly  characterized  by  failure  of 
memory  respecting  recent  events,  while  the  long  past  is 
often  remembered  -with  considerable  accuracy.  There  is  also 
more  or  less  incoherence  of  ideas.  Sometimes  there  are  de- 
lusions which  are  seldom  persistent,  though  while  they  last 
they  may  incite  to  violence.  Feebleness  of  purpose  and 
facility  of  disposition  are  ordinary  features.  Cases  are  to  be 
met  with  in  which  there  are  occasional  attacks  of  maniacal 
excitement,  lasting  for  a  few  days,  and  followed  by  depres- 
sion and  exhaustion.  A  tendency  to  indecency  of  conduct 
has  been  manifested  in  a  number  of  instances.  The  physical 
signs  of  old  age  accompany  this  mental  condition.  From 
various  causes  senility  may  appear  long  before  the  usual 
period  of  life. 

Senile  dementia  may  occur  in  a  different  form,  presenting 
at  its  commencement  features  resembling  a  common  vai'iety 
of  monomania,  that,  namely,  of  suspicion.  Groundless 
jealousy  of  near  relatives  and  aversion  to  them  may  be  the 
earliest  marked  symptoms :  but  there  are  usually  also  other 
indications  of  mental  disturbance,  such  as  violent  explosions 
of  anger  from  trifling  causes,  along  with  strange  and  extrava- 
gant conduct,  quite  at  variance  with  the  previous  disposition 
of  the  individual.  Ere  long  failing  memorv'  and  other  evi- 
dences of  general  intellectual  enfeeblement  reveal  the  ad- 
vancement of.  the  mental  decay. 

Although  dementia  is  the  usual  form  of  mental  derange- 
ment in  advanced  life,  it  would  be  a  mistake  to  suppose  that 
it  is  the  only  one  ;  both  monomania  and  mania  are  met  with 
occasionallv.  But  occurring  then,  these  other  forms  often 
partake  somewhat  of  dementia. 

Organic  dementia  is  the  name  given  to  a  variety  Avhich 
occasionally  follows  apoplectic  seizures  where  there  is  no 
paralysis,  or  which  is  associated  with  hemiplegia  or  other 
obvious  organic  disease  of  the  braiii.  In  the  majority  of 
hemiplegics,  both  old  and  young,  there  is  marked  emotional 
weakness,  manifested  by  a  tendency  to  weep  immoderately 
to  ajjpearance,  though  it  is  seldom  that  any  tears  are  shed. 
Occasionally  in  the  same  person  there  is  an  equal  readiness 
to  laugh,  but  the  fit  of  laughter  generally  ends  in  weeping  of 
the  form  described.  The  memory  is  also  weak  and  the 
judgment  impaired.  When  the  paralysis  is  on  the  right  side, 
and  is  accompanied  by  aphasia,  there  is,  as  a  rule,  less  indi- 
cation of  weakened  feeling  than  when  it  is  on  the  left  side. 
In  very  many  cases  of  organic  dementia  the   patients  are 


PRIMARY    DEMENTIA — IDIOCY.'  247 

stupid,  silly,  and  facile ;  and  on  the  physical  side,~besides 
paralysis,  they  suffer  from  disease  of  the  heart  or  kidneys 
and  frequently  of  both  organs. 

Acute  or  primary  demeiitia  is  very  different  in  its  nature 
from  the  varieties  which  have  been  described.  It  occurs'in 
the  young,  more  frequently  in  women  than  in  men,  and  is 
prone  to  affect  those  who  are  naturally  feeble-minded  and 
excitable,  more  particularly  if  there  be  a  hereditary  tendency 
to  insanity.  It  is  usually  the  result  of  a  severe  mental  shock, 
such  as  fright,  unexpected  bad  news,  &c. ;  and  its  occurrence 
is  often  quite  sudden,  or  within  a  few  days  after  the  shock 
has  been  sustained.  The  powers  of  the  mind  are  in  almost 
complete  abeyance,  but  they  are  not  destroyed.  The  patients 
stare  vacantly  when  addressed,  evidently  not  understanding 
"what  is  said  to  them.  They  perhaps  make  grimaces  or  per- 
form actions  automatically,  but  more  commonly  they  remain 
in  the  same  position,  unless  moved  from  it,  their  arms  hang- 
ing heavily  by  their  sides,  and  their  aspect  blank  and  stupid. 
Their  circulation  is  languid,  the  extremities  and  features 
being  bluish,  and  their  general  condition  is  soft  and  flabby. 
Nutrition  is  not  well  maintained,  and  they  occasionally 
become  considerably  emaciated.  They  are  often  inattentive 
to  the  calls  of  nature.  The  prognosis  of  this  form  is  gene- 
rally favorable,  but  the  writer  has  seen  several  cases,  espe- 
cially when  the  cause  was  fright,  where  the  disorder  became 
permanent.  He  has  also  observed  an  attack  of  acute  mania 
intervene  between  this  state  and  recovery.  Usually,  how- 
ever, it  gradually  passes  away,  pari  passu,  with  the  restora- 
tion of  the  general  health. 

It  will  be  observed  that  acute  dementia  resembles  some- 
Vfhat  closely  "  melancholy  with  stupor."  The  two  forms  are 
distinguished  chiefly  by  the  facial  expression ;  in  the  latter 
— at  least  in  the  more  common  variety — it  is  intent  and 
fixed,  indicative  of  the  profound  mental  concentration  ; 
whereas,  in  the  former,  it  is  vacant  and  meaningless.  How- 
ever, in  cases  where  the  element  of  stupor  predominates 
over  the  melancholy,  the  diagnosis  is  sometimes  very 
difficult. 

Idiocy Idiots,  considered  pathologically,  have  been  ar- 
ranged by  Dr.  Ireland  into  ten  different  groups  ;  but  looked 
at  broadly  and  generally,  in  relation  to  their  symptoms,  they 
may  be  divided  into  two  great  classes — the  apathetic  and 
the  agitated — between  which  there  is  every  grade.  Indi- 
viduals of  the  lower  types  of  the  first  class  have  often  awk- 


248  INSANITY. 

ward,  clumsy,  and  ill-proportioned  bodies  and  coarse  fea- 
tures ;  lips  thick  and  everted  ;  teeth  irregular  and  decayed ; 
gums  swollen ;  ears  ill-formed  and  large.  Their  heads  are 
in  general  of  good  size,  and  are  sometimes  larger  than  the 
average  ;  but  they  are  misshapen  and  not  unfrequently  flat- 
tened in  the  occipital  region.  Mentally  they  are  often 
gloomy,  generally  passive,  but  sometimes  passionate  and 
dangerous.  The  agitated  class  are  quick  and  flighty,  and 
run  about  laughing,  crying,  and  gesticulating.  They  are 
subject  to  bursts  of  passion,  and  are  often  pugnacious. 
They  have  in  general  abnormally  small  but  well-formed 
heads.  In  both  classes  attention  and  perception  are  exceed- 
ingly feeble  ;  there  is  little  memory  and  less  judgment ;  and 
the  will  is  imperfect — their  acts  being  usually  the  results  of 
impulses  originating  in  their  sensations.  Occasionally  there 
is  an  exceptional  development  of  a  particular  faculty  or 
talent,  most  frequently  that  of  music.  Speech  is  very  defec- 
tive, and  many  cannot  articulate  at  all ;  squint  is  common  ; 
and  a  large  proportion,  especially  where  the  condition  is  con- 
genital, have  what  has  been  called  the  saddle-shaped  palate 
• — that  is,  a  palate  whose  arch  is  considerably  higher  than 
the  normal.  A  large  proportion  have  a  tendency  to  be  of 
dirty  habits,  and  occasionally  the  sexual  appetite  is  very 
strongly  developed. 

Idiots,  as  well  as  imbeciles,  and  particularly  the  latter, 
may  have  attacks  of  melancholia,  or  monomania,  but  most 
frequently  of  mania.  The  acquired  disorder  may  pass  away, 
leaving  the  patient  much  as  before  the  seizure,  or  it  may 
continue  to  some  extent,  modifying  the  original  condition. 

Dr.  Ireland  holds  that  even  in  early  infancy  idiocy  may 
be  recognized  by  the  slowness  or  awkwardness  of  the  child's 
motions.  He  says:  "  If  laid  flat  upon  his  face,  he  will  sink 
upon  the  floor,  whereas  a  normal  child  of  a  few  months  will 
try  to  right  itself,  or  cry  for  assistance."  When  a  little 
older,  the  wandering,  unsettled  eye,  the  inability  to  fix  the 
attention,  the  slowness  and  inaptitude  to  learn,  and  tlie 
general  vacancy  of  expression,  reveal  the  mental  defect. 
The  state  of  the  palatal  arch,  when  present,  is  a  valuable 
aid  to  diagnosis. 

The  Diagnosis  op  Insanity  from  Delirium It  is 

first  of  all  to  be  noticed  that  in  certain  cases  there  is  no  real 
difference  between  insanity  and  delirium  :  thus  mania,  oc- 
curring in  the  course  of  pneumonia  or  in  an  advanced  stage 
of  phthisis  pulmonalis,  is  sometimes  simply  delirium  of  an 


DIAGNOSIS    OF    INSANITY.  249 

acute  type.  However,  cases  in  ■which  the  two  states  approxi- 
mate so  closely  are  not  very  common,  and  in  general  the 
distinction  is  quite  obvious,  being  mai'ked  by  definite  charac- 
ters.  (Compare  p.  198.) 

Delirium  is  very  generally  preceded  for  some  days  by 
other  and  more  characteristic  symptoms  of  the  disease  on 
which  itself  is  dependent.  Shoidd  that  be  inflammation  of 
the  lungs  or  brain  or  other  leading  organ ;  or  severe  injury 
of  extremities  or  other  parts,  inducing  inflammation;  or  one 
of  the  speciiic  fevers,  or  smallpox,  or  other  animal  poison  in 
the  system ;  ordinary  symptoms  of  the  particular  morbid 
state  will  usually  have  been  manifest  before  the  mental  dis- 
turbance appears.  The  character  of  the  delirium  in  the  first 
instance,  and  also  often  throughout  its  entire  course,  is  in 
most  cases  quiet  rambling  or  incoherence,  and  these  symp- 
toms are  most  apt  to  show  themselves  at  night,  especially 
when  the  patient  is  drowsy,  and  no  one  is  addressing  him. 
Associated  with  it  there  are  also  frequently  hallucinations, 
particularly  of  visions.  Occasionally,  however,  the  excite- 
ment is  greater,  and  the  patient  can  with  difficulty  be  con- 
trolled. Should  it  spring  up  after  injury  in  one  of  drunken 
habits,  we  have  often  much  excitement  and  violence,  along 
with  fear  and  hallucinations.  This  state  frequently  partakes 
more  of  ephemeral  mania  than  of  ordinaiy  delirium  tremens. 
But  though  delirium  is  usually  a  late  event  in  the  disease  of 
which  it  is  symptomatic,  occasionally,  and  particularly  in 
children,  it  occurs  early  in  its  course  ;  in  that  case,  however, 
it  is  accompanied  by  a  temperature  markedly  elevated,  and 
by  other  acute  febrile  symptoms. 

The  physical  symptoms  that  accompany  delirium  are  com- 
monly high  temperature,  very  quick  pulse,  furred  dry  tongue, 
parched  skin,  injected  conjunctivne,  scanty  high-colored 
urine,  &c — in  fact  such  as  indicate  the  febrile  state.  These, 
it  will  be  observed,  do  not  correspond  with  the  condition  in 
the  most  common  form  of  acute  mania,  where  the  febrile 
action  is  slight,  if  there  be  any  at  all.  In  establishing  the 
diagnosis  no  symptom  is  so  reliable  as  the  temperature.  In- 
deed, the  determination  of  this  point  may  be  regarded  as  of 
so  much  importance  that  it  might  be  laid  down  as  a  rule 
that  in  any  case  where  the  temperature  is  distinctly  above 
the  normal,  as  ascertained  by  the  thermometer,  or  even  by 
the  hand,  if  the  thermometer  cannot  be  used,  the  examina- 
tion should  not  be  regarded  as  complete  until  it  be  ascer- 
tained if  inflammatory  action  in  one  of  the  leading  organs, 


250  INSANITY. 

or  if  one  of  the  continued  fevers,  does  not  occasion  the  men- 
tal disturbance.  In  delirious  mania,  however,  tliere  is  often 
elevated  temperature  with  other  febrile  indications,  but  they 
are  seldom  so  marked  as  in  ordinary  delirium.  Further,  in 
this  form  of  mania  the  excitement,  as  a  rule,  is  higher  and 
more  constant  than  in  delirium,  continuing  without  the  least 
remission,  or  with  snatches  of  sleep  of  not  more  than  half  an 
hour  or  an  hour  in  duration,  for  days  and  nights  together  : 
whereas  the  excitement  and  incoherence  of  delirium  generally 
vary  considerably  in  their  intensity,  being  often  worse  at 
night  than  during  the  day. 

Much  aid  in  the  formation  of  the  diagnosis  will  be  obtained 
by  the  observation  of  the  special  symptoms  of  local  disease, 
should  these  be  present.  It  is  probably  most  frequently  in 
relation  to  the  early  stage  of  acute  meningitis  that  doubt 
arises.  In  it  thei-e  is  generally  injection  of  the  eye  and 
flushing  of  the  face,  intolerance  of  light  and  sound,  consid- 
erable headache,  vomiting,  contracted  pupils,  pain  and 
sjiasmodic  movements  in  the  extremities,  and  high  tempera- 
ture, and,  as  the  disease  progresses,  squinting,  general  con- 
vulsions, dilated  pupils,  &c. 

It  will  be  sufficient  to  mention  that  typhus  fever  has  been 
mistaken  for  mania:  the  high  temperature,  parched  skin, 
ferretty  eyes,  and  eruption,  with  history,  should  make  the 
diagnosis  clear. 

From  the  observations  that  have  been  made,  it  will  be 
understood  that  the  diagnosis  of  delirium  from  the  varieties 
of  mania  which  it  at  all  resembles,  rests  much  more  on  the  his- 
tory of  the  illness  and  on  indications  of  existing  acute  physi- 
cal disease  than  on  any  very  marked  diiference  between  the 
mental  symptoms  in  the  two  conditions. 

Mere  drunkenness  has  been  mistaken  for  insanity  even  by 
medical  men.  A  little  inquiry  into  the  case,  and  the  obser- 
vation of  the  too  familiar  symptoms  of  intoxication  should 
pi-event  such  an  error. 

The  Mode  of  examining  a.  Person  supposed  to  be 
Insane  is  a  matter  of  considerable  importance.  There  is 
generally  little  difficulty  where  ordinary  mania  or  melan- 
cholia are  concerned,  at  all  events  when  they  are  fully  devel- 
oped :  it  is  experienced  most  frequently  in  the  varieties  of 
partial  insanity.  In  some  cases  even  the  introduction  to  the 
supposed  lunatic  is  no  easy  matter.  No  general  rule  of  pro- 
cedure can  possibly  be  laid  down,  as  this  must  vary  accord- 
ing to  the  social  status,  the  habits,  the  mental  peculiarities, 


MODE    OF    EXAMINING    A    LUNATIC.  251 

and  many  other  circumstances.  The  frank  bluntness  oF  ad- 
dress that  might  suit  a  laborer  would  scarcely  be  acceptable 
to  an  educated  gentleman.  The  writer's  practice  is  generally 
— not  in  all  cases — to  drop  the  title  of  ''Dr."  and  to  be  in- 
troduced as  "Mr."  It  has  seemed  sometimes  that  the  an- 
nouncement of  the  medical  title  has  at  once  aroused  a  feeling 
of  suspicion  and  hostility,  and  rendered  the  inquiry  very 
difficult.  A  few  easy  general  observations  may  sutfice  to 
establish  agreeable  relations  between  the  physician  and  the 
patient  before  the  professional  nature  of  the  visit  is  revealed. 
This  in  the  great  majority  of  cases  it  would  be  unwise  to  try 
to  conceal,  as  most  patients  would  at  once  resent  any  attempt 
at  deception.  It  will  often,  then,  be  advisable  to  quietly 
state  to  the  patient  that  you  are  a  physician ;  that  you  un- 
derstand from  his  relatives  that  he  has  been  somewhat  out 
of  sorts  lately;  that  possibly  it  might  be  only  supposition 
on  their  part,  but  it  would  allay  tlieir  anxiety  if  he  would 
kindly  answer  a  few  questions  respecting  his  health.  This 
being  conceded,  it  will  be  well  in  the  first  instance  to  make 
some  medical  inquiries  of  an  ordinary  kind  and  then  to  ex- 
tend the  investigation  to  the  special  senses,  particularly  those 
of  hearing  and  sight.  Cautiously  ask  respecting  noises  in 
the  ear,  and  if  they  resemble  whispers  or  loud  voices,  and 
what  they  say;  and  in  relation  to  the  eyes,  if  motes  or  other 
unusual  objects  be  seen,  if  they  assume  special  forms,  and  if 
so,  what  they  are  like.  Then  lead  the  conversation  on  to 
matters  relating  to  home  and  family,  business  prospects,  re- 
ligious views,  &c.  Of  course  the  particular  line  of  inquiry 
will  frequently  be  guided  by  information  previously  obtained 
from  relatives  and  friends,  though  this  in  some  cases  is  in- 
correct and  in  others  is  defective.  It  occasionally  happens 
that  near  relatives  who  are  constantly  beside  the  patient  are 
quite  unaware  of  the  existence  of  dangerous  delusions.  In 
most  cases  the  general  bearing  and  expression  of  countenance 
indicate  the  nature  of  the  morbid  ideas ;  and,  especially 
where  the  history  is  imperfect,  this  guide  will  save  an  im- 
mense amount  of  trouble  by  at  once  suggesting  the  kind  of 
questions  best  fitted  to  draw  them  out.  The  psychological 
physician  should  be  skilled  in  physiognomy.  Many  useful 
hints  in  prosecuting  the  investigation  are  also  frequently  ob- 
tained by  the  observation  of  peculiarities  of  dress,  oddities 
about  the  room,  and  sundry  other  things. 

But  perhaps  at  the  very  commencement  of  the  interview 
the  patient  indignantly  resents  the  idea  that  he  is  ill  at  all. 


252  INSANITY. 

Then  the  most  judicious  phin  will  sometimes  be  to  sympa- 
thize with  his  indignation;  to  ask  what  could  have  made 
the  relatives  suppose  that  his  health  was  impaired ;  and  to 
inquire  if  it  could  be  due  to  any  plot  or  conspiracy,  and  it 
so,  what  may  be  the  motive.  This  may  bring  out  delusions 
of  suspicion,  which  are  common  in  cases  where  difficulty  in 
the  examination  is  experienced.  Occasionally  a  lunatic 
who  is  very  reticent  in  conversation,  will  express  his  views 
more  freely  in  writing,  and  in  this  way  the  existence  of  de- 
lusions may  be  ascertained. 

These  observations  illustrate  the  general  method  of  pro- 
cedure :  they  cannot  do  more,  as  the  investigation  in  each 
case  ought  to  be  based  on  the  features  which  are  peculiar  to 
it.  It  need  only  be  further  remarked  that,  should  the  patient 
be  melancholic,  the  inquiry  ought  always,  if  possible,  to 
demonstrate  the  presence  of  a  disposition  to  suicide  Avhen  it 
exists,  as  it  so  often  does  in  this  condition.  Generally  the 
point  may  be  determined  by  indirect  questions,  but  occa- 
sionally it  is  necessary  to  ask  the  patient  plainly  if  he  is 
weary  of  life  and  contemplates  self-destruction. 

Family  History.  As  insanity  is  a  highly  hereditary 
disease,  it  is  important  to  inquire  respecting  its  existence  in 
the  family  to  which  the  patient  belongs.  But  the  inquiry 
should  not  be  restricted  to  mental  disorder,  as  it  is  now  well 
established  that,  in  the  descent  from  one  generation  to  another, 
various  neurotic  affections — such  as  epilepsy,  chorea,  hys- 
teria, a  disposition  to  habitual  drunkenness,  particularly  in 
its  paroxysmal  form,  &c.,  are  mutually  interchangeable  (com- 
pare p.  65).  Thus  it  is  common  for  an  epileptic  parent  to 
beget  an  idiotic  or  imbecile  child ;  or  conversely,  the  off- 
spring of  an  imbecile  father  or  mother,  or  of  one  who  has 
been  insane,  or  is  of  the  insane  temperament,  may  be  epilep- 
tic or  idiotic.  The  prognosis  of  the  mental  illness  would  be 
more  serious  if  a  strong  hereditary  taint  were  present :  not 
that  the  prospect  of  recovery  from  an  attack  of  insanity, 
which  otherwise  might  be  curable,  would  thereby  be  much, 
if  at  all,  diminished ;  for  this  is  scarcely  less  frequent  than 
Avhere  no  such  taint  is  in  the  constitution.  There  would, 
however,  as  an  expression  of  the  ancestral  defect,  be  a  greater 
tendency  for  the  type  of  disease  to  be  more  grave  from  the 
beginning — showing  itself,  for  instance,  at  first  as  a  slight 
deviation  from  the  normal  standard,  and  then  gradually 
merging  into  incurable  insanity.  As  a  further  illustration 
of  the  constitutional  vice,  it  is  worthy  of  note  that  in  patients 


QUESTION    OF    ASYLUM    TREATMENT.  253 

"R'ho  have  recovered  from  one  or  more  attacks,  recurreivce  is 
particularly  to  be  dreaded.  The  lower  forms  of  mental  dis- 
ease, such  as  imbecility"  or  idiocy,  are  peculiarly  apt  to  be 
transmitted  from  parent  to  child,  and  a  repetition  of  consan- 
guineous marriages  in  the  lamily  is  apt  to  become  very  dis- 
astrous in  this  way.  The  establishment  of  puberty  is  very 
trying  to  the  mental  stability  of  those  in  wliom  a  marked 
hereditary  tendency  exists,  especially  to  women  ;  so  also  are 
pregnancy  and  childbirth.  Experience  shows  that,  as  a  rule, 
the  hereditary  tendency  is  more  prone  to  be  transmitted  from 
father  to  son  than  from  father  to  daughter,  and  from  mother 
to  daughter  than  from  mother  to  son.  It  is  to  be  borne  in 
mind  that  the  existence  of  insanity  in  the  family  is  often 
denied  by  the  relatives.  The  inquiry  is  a  delicate  one,  and 
should  be  carried  out  with  consideration  for  the  feelings  ot 
those  concerned. 

Question  of  Asylum  Treatment If  the  medical  ex- 
aminer be  satisfied  that  his  patient  is  insane,  he  will  next 
require  to  consider  what  advice  he  should  give  to  the  friends 
— whether  he  should  recommend  immediate  removal  to  an 
asylum,  or  a  trial  of  treatment  at  home,  or,  at  all  events,  else- 
where than  in  such  an  institution  :  the  matter  is  one  of  great 
practical  importance,  and  is  at  the  same  time  one  sometimes 
very  difficult  to  determine.  Many  considerations  besides 
those  of  a  medical  character  must  be  weighed  in  seeking  to 
arrive  at  a  correct  conclusion.  Thus  it  will  be  obvious  that 
if  the  patient  be  wealthy,  and  have  kind,  judicious  relatives, 
and  if  his  house  be  in  a  retired  situation  and  have  private 
ground  attached,  it  will  not  be  necessary  to  insist  on  so  early 
removal  to  an  asylum  as  if  he  be  a  laborer  living  in  a  small 
liouse  in  a  crowded  neighborhood ;  for  in  the  former  case 
the  patient  already  possesses,  or  can  readily  procure,  many 
of  the  advantages  which  an  asylum  presents,  but  which  the 
poorer  man  can  have  nowhere  else.  But  though  these  points 
ought  to  form  an  important  element  in  the  judgment,  the 
main  gi-ounds  will  rest  in  the  character  of  the  disorder  itself. 
The  indications  derived  from  it,  however,  can  only  be  stated 
in  a  general  way.  Should  the  insanity,  though  characterized 
by  a  considerable  amount  of  excitement,  be  quite  sudden  in 
its  onset,  without  distinct  premonitory  symptoms,  the  attack 
often  passes  away  quickly;  a  sudden  seizure  should  then, 
other  circumstances  not  being  unfavorable,  dispose  to  a  trial 
of  home  treatment.  More  particularly,  the  following  forms 
are  frequently  of  short  duration,  namely,  those  tliat  residt 
22 


254  INSANITY. 

from  alcohol,  with  the  exception  of  the  paralytic  dementia 
produced  by  that  agent ;  the  milder  attacks  of  mania  that 
are  apt  to  occur  about  the  establishment  of  puberty  in  both 
sexes,  especially  in  the  female ;  the  so-called  metastatic  forms, 
occurring  in  rheumatic  and  gouty  constitutions  ;  the  slighter 
seizures  after  childbirth  and  through  over-lactation,  though 
there  is  considerable  uncertainty  respecting  both  of  them  :  in 
all  these  cases  the  medical  attendant  would  be  justitied  in 
advising  that  the  effects  of  medicinal  agents  and  other  meas- 
ures at  home  should  be  tested  in  the  first  instance.  Patients 
suffering  from  mild  types  of  melancholia  are  also  frequently 
treated  under  the  care  of  relatives  ;  but  the  physician  must 
never  forget  the  tendency  to  suicide  in  such  cases.  Attacks 
of  epileptic  insanity  likewise  generally  soon  pass  away,  but 
then  they  not  infrequently  recur  in  connection  with  fresh 
seizures  ;  and,  indeed,  the  mental  state,  even  at  its  best,  of 
epileptics  who  have  reached  this  stage  of  their  disease  is 
commonly  such  that  the  asylum  is  the  most  suitable  place  for 
them.  On  the  other  hand,  insanity  of  slow  development, 
which  has  gradually  attained  a  considerable  degree  of  in- 
tensity, is  not  likely  to  be  of  short  duration  ;  general  paraly- 
sis is  an  unmanageable  as  well  as  an  incurable  form ;  and 
varieties  which  present  suicidal  or  homicidal  features,  or 
both,  are  dangerous:  all  these  should  be  consigned  to  an 
asylum  at  once.  Further,  with  respect  to  the  class  in  which 
this  extreme  measure  may  have  been  at  first  delayed,  should 
there  be  no  improvement,  and  particularly  should  there  be 
rather  an  aggravation  of  the  symptoms  after  ten  days  or  a 
fortnight  of  treatment  at  home,  it  will  then  in  most  cases  be 
the  wisest  course  to  recommend  removal  to  an  asylum. 


255 


CHAPTER  IX. 

DISORDERS  OF  THE  RESPIRATORY  AXD 
CIRCULATORY  SYSTEM.' 

Dyspxcea,  want  of  breath,  difficulty  in  breathing,  pain  in 
the  chest,  palpitation  of  the  heart,  cardiac  spasm  and  anguish, 
a  sense  of  impending  suiFocation,  and  all  forms  of  labored 
and  obstructed  breathing,  require  so  far  to  be  considered  in 
one  groap,  as  they  frequently  simulate  each  other,  or  become 
mixed  up  together.  Tliey  depend  on  the  most  diverse  causes. 
Amongst  these  may  be  named  nervous  or  spasmodic  asthma  ; 
inflammatory  affections  of  the  larynx,  trachea,  lungs,  bron- 
chi, pleura,  and  pericardium ;  destruction  of  the  lung  and 
perforation  of  the  pleura  with  pneumothorax  ;  inflammations 
or  abscesses  about  the  throat,  larynx,  or  oesophagus ;  various 
forms  of  cardiac  disease ;   aneurismal    and    other    thoracic 

1  Tlie  subjects  dealt  with,  in  tliis  cliapter  are  usually  treated  of 
pretty  fully  in  the  various  text  books  of  medicine.  They  must  also 
be  considered  in  connection  with  the  physical  examination  of  the 
chest  (see  Chapter  xvi.  of  this  book,  and  the  works  referred  to 
there).  Vols.  III.  and  IV.  of  Reynolds's  "System,"  and  Vols.  IV., 
v.,  and  VI.  of  Ziemssen's  "  Cyclopjedia"  may  be  consulted  for  full 
articles.  Walshe  on  Diseases  of  the  Heart  and  Lungs  ;  Salter  on 
Asthma  ;  Hayden,  Balfour,  and  Sansom  on  Diseases  of  the  -Heart  ; 
Waters  on  Diseases  of  the  Chest,  &c.,  may  also  be  named;  and 
likewise  Gairdner's  papers  on  Bronchitis  {Edinhurgh  Montlily  Journal, 
1850—51),  various  chapters  in  his  "Clinical  Medicine,''  and  his 
article  on  Angina  Pectoris  in  Reynolds's  "  System,"  Vol.  IV.  The 
classical  treatise  of  Laenuec  may  also  be  consulted.  Some  of  the 
subjects,  such  as  Pertussis,  Laryngismus  stridulus,  Croup,  and 
Diphtheria,  are  dealt  with  very  fully  in  works  on  the  diseases  of 
children.  Surgical  treatises,  especially  Holmes's  "System,"  and 
Holmes's  work  on  "The  Surgical  Treatment  of  the  Diseases  of 
Infancy,"  contain  mucli  that  demands  attention,  on  subjects  con- 
nected with  disorders  of  the  throat,  the  hemorrhagic  diathesis,  &c. 
Trousseau's  lectures  may  be  referred  to  with,  great  advantage  on 
many  of  tlie  matters  under  consideration.  The  description  of  the 
newer  methods  of  examining  the  blood  are  only  to  be  found,  as 
yet,  in  the  various  periodicals.  Dr.  Wm.  Roberts's  lecture  on  Con- 
tatjium  Vifum  may  be  referred  to  for  a  short  statement  on  the  organ- 
isms found  in  the  blood.     See  also  Bennett  on  Leucocytlisemia. 


256       DYSPN'CEA,    PALPITATION,    THORACIC    PAIX. 

tumors  ;  thrombosis  and  embolism  of  the  pulmonarv  arterv, 
dropsy  of  the  abdomen  and  of  tlie  pleura  and  pericardium  ; 
abdominal  swelling  and  tumors  when  bulky,  and  e\en  some 
Avhich  are  not  very  large  (including  the  gravid  uterus)  ;  spasm 
of  the  glottis  as  an  isolated  affection  (laryngismus  stridulus), 
as  well  as  an  incident  in  other  diseases  ;  ura?mic  conditions 
and  other  forms  of  defective  renal  activity ;  and  certain 
varieties  of  ana-mia,  chlorosis,  and  hysteria. 

DYSPNCEA,  PALPITATION,  THORACIC  PAIX,  &c. 

The  subject  of  Dyspnoea  must  be  approached  in  various 
ways.  (1)  By  ti-ying  to  discover  fi'omthe  patients  the  char- 
acter of  their  distress,  and  the  causes  of  its  aggravation,  as 
noticed  by  themselves.  (2)  By  observing  the  patient  as  re- 
gards the  number  of  respirations,  the  appearance  of  laborious 
breathing,  the  evidence  of  acute  suffering,  or  of  mortal  terror; 
by  noticing  any  appearance  of  cyanoses  and  lividity,  or  of 
pallor  in  the  face  ;  and  by  scrutinizing  the  sounds,  whether 
crowing,  hoarse,  gurgling,  or  choking,  emitted  during  respi- 
ration. We  must,  likewise,  notice  the  attitude  assumed  by 
the  patient  during  an  attack,  and  the  character  of  the  cough 
and  expectoration  when  these  are  present.  (See  pp.  2 GO, 
268,  273.)  Paroxysms  of  coughing  from  any  cause  may  of 
themselves  produce  considerable  dyspnoea,  and  frequently 
aggravate  it  when  they  are  severe.  (3)  By  an  appreciation, 
where  this  is  possible,  of  tlie  previous  facts  or  history  of  the 
case  ;  particularly  as  to  any  known  disease  in  the  heart,  lungs, 
pleura  or  pericardium,  or  anything  likely  to  lead  to  perfo- 
ration.of  the  pleura  (phthisis,  abscess,  &c.) ;  anv  rheumatic 
attack  likely  to  give  rise  to  pericarditis  or  endocarditis  ;  any- 
thing predisposing  to  thrombosis  or  embolism  in  the  pulmo- 
nary artery  (the  puerperal  state,  venous  thrombi,  and  dilated 
heart)  ;  any  condition  predisposing  to  rapid  dropsy,  especially 
into  the  pleura,  pericardium,  or  pulmonary  tissue  (scarlatinal 
nephritis  in  particular)  ;  any  known  tendency  to  angina  pec- 
toris or  spasmodic  asthma  in  the  individual  or  in  his  family; 
and  any  preliminary  symptoms  of  diphtheria,  croup,  or  laryn- 
gitis. (4)  By  an  examination  of  the  thoracic,  and  other 
organs.  By  this  we  can  often  detect  whether  the  air  is  pre- 
vented from  entering  the  lungs  by  tumor,  pressure,  or  spasm 
in  the  upper  portions  and  larger  divisions  of  the  respiratory 
tract,  or  by  the  presence  of  fluid  or  air  in  the  pleura,  or  by 
oedema  and  exudation  into  the  bronchi,  or  by  other  forms  of 


BATE    OF    RESPIRATION.  257 

pulmonaiy  or  pleuritic  disease.  We  can  sometimes  also  de- 
tect evidences  of  heart  disease,  pericarditis,  or  effusion, 
although  the  distressed  state  of  the  patient  is  not  favorable 
for  a  careful  examination  of  the  chest  ;  dropsical  accumula- 
tions or  tumors  in  the  abdomen  pressing  on  the  heart  and 
lungs  can  be  readily  observed,  and  the  state  of  the  urine  may 
throw  much  light  on  the  case.  An  examination  of  the  throat 
for  an  abscess  of  the  tonsils,  or  for  one  bulging  behind  the 
pharynx,  for  diphtheritic  patches  in  the  fauces,  or  for  tender- 
ness over  the  larynx,  is  of  great  importance,  especially  in 
children.  Laryngoscopic  examination  can  seldom  be  prac- 
tised in  the  heiglit  of  an  attack,^  but  on  its  partial  subsidence 
we  may  find  evidence  of  thickening  and  ulceration  of  the 
cords,  or  tumors,  cedema,  or  abscess,  in  this  situation,  giving 
rise  to  mechanical  obstruction  or  recurring  spasm  ;  or  we  may 
find  paralysis  of  one  of  the  cords  indicating  ratlier  the  origin 
of  the  attacks  in  some  irritation  of  the  laryngeal  nerves  lower 
down.  (Many  of  these  subjects  are  dealt  with  in  other  sec- 
tions of  this  book,  as  v\'ill  be  seen  on  consulting  the  Index.) 
The  number  of  respirations  per  minute  affords  an  impor- 
tant indication  of  dyspnoea.  The  normal  rate  may  be  stated 
as  about  18  to  20  per  minute  in  the  male  adult  while  awake, 
but  variations  of  from  12  to  24  are  not  uncommon.  In  chil- 
dren, and  also  in  women,  the  rate  is  somewhat  more  rapid. 
Like  the  pulse,  it  is  much  affected  by  different  postures,  and 
by  sleep,  agitation,  exertion,  coughing:,  and  swallowing.  The 
respiration  is  particularly  apt  to  be  deranged  in  its  rhythm 
when  the  attention  is  directed  to  it,  so  that  we  must  try  to 
count  its  rate  apart  from  the  patient's  knowledge.  This  may 
be  done  very  well  while  taking  the  pulse,  by  continuing  to 
hold  the  patient's  wrist,  while  we  watch  the  movements  of 
the  chest,  and  count  them  for  half  a  minute  ;  or,  if  these  are 
not  very  visible,  we  may  lay  the  hand  or  a  finger  very  liglitly 
and  as  if  by  accident,  on  the  chest  wall,  under  the  clavicle 
in  the  female  and  below  the  xiphoid  in  the  male :  in  other 
cases  we  can  count  best  by  listening  to  the  breathing,  or  by 
watching  the  movements  of  the  bed-clothes.  In  critical  es- 
timations of  the  rate  of  breathing  we  watch  for  a  quiet  period, 
or  take  some  opportunity  of  noting  the  number  while  the  pa- 
tient is  asleep,  or  at  least  before  he  is  disturbed  by  speaking, 
moving,  or  crying. 

1  Even  then  an  examination  bj  the  finger  may  give  some  impor- 
tant information  (see  Chapter  x.). 

22* 


258      DYSPNCEA,    PALPITATION,    THORACIC    PAIN. 

In  febrile  states,  from  whatever  cause,  the  respiration  is 
quickened,  the  inci'ease  keeping  a  certain  proportion  to  that 
of  the  pulse  ;  the  ratio  in  health  is  1  respiration  to  about  4 
or  4,0  beats  of  the  pulse,  and  so  long  as  something  like  this 
ratio  is  maintained,  the  increase  may  be  ascribed  simply  to 
the  fever.  "When  the  rapidity  of  the  respiration  exceeds 
this  proportion,  vce  infer  the  existence  of  some  respiratory 
disorder.  An  attack  of  bronchitis,  for  example,  may  be 
detected  in  this  way  in  the  course  of  typhus.  The  respira- 
tion is  accelerated  in  nearly  every  variety  of  disease  of  the 
respiratoi-y  organs,  in  acute  or  sub-acute  forms,  and  this 
constitutes  one  of  the  features  of  nearly  every  kind  of  dysp- 
noea. The  number  is  often  40  or  50,  it  sometimes  rises  to 
60  or  80  per  minute,  and  may  almost  equal  the  pulse-rate  (1 
respiration  to  1.25  pulse-beat). 

The  respiration  is  somewhat  rapid  and  easily  accelerated 
in  certain  non-febrile  states,  even  apart  fi-om  any  special 
respiratory  complication  ;  the  debility  after  fever,  and  cer- 
tain ana:^mic  conditions,  may  be  mentioned  amongst  these. 
In  Rickets,  the  rapid  breathing  may  be  due  to  the  general 
state,  and  to  the  great  liability  of  ricketty  children  to  pul- 
monary collapse. 

The  apiJearance  of  lahor  in  hreatMng  is  of  great  import- 
ance.^ There  may  be  very  rapid  breathing  without  any 
great  effort  or  labor,  but  any  additional  strain  may  show  at 
once  that  the  breathing  is  maintained  at  the  extreme  limit 
of  the  patient's  power;  any  exertion,  such  as  sitting  up  in 
bed,  and  speaking,  or  anything  which  demands  additional 
efforts,  brings  out  the  patient's  weakness  in  this  respect  ;  he 
says  a  word  or  two  and  stops  to  recover  breath,  and  then  re- 
sumes. A  striking  illustration  of  the  same  thing  is  found  in 
ini'antiie  dyspnoea  ;  the  child's  whole  energy  is  required  for 
breathing,  and  so  after  a  momentary  attempt  at  sucking,  or 
after  one  or  two  such  attempts,  he  refuses  the  breast,  although 
obviously  anxious  to  drink,  and  probably  very  thirsty  :  this 
refusal  is  an  important  fact  in  the  pneumonia  and  suffocative 
bronchitis  of  children.  In  uncomplicated  pneumonia  and 
some  other  diseases  characterized  by  rapid  breathing,  no 
great  eflbrt  is  visible,  but  tlie  state  of  matters  is  very  differ- 
ent in  cases  where  an  obstruction  exists  to  the  entrance  of 
air  through  the  glottis,  trachea,  or  bronchi, — whether  this 
arises  directly  from  mechanical  obstruction  or  from   nervous 

'  See  also  remarks  under  Xervous  Dyspnoea,  page  267. 


SUDDEN    DYSPN(EA.  259 

spasm.  Hence  in  laryngeal  obstructions,  and  spasm  ^rora 
any  cause,  in  croup,  in  spasmodic  asthma,  and  in  bronchitis 
and  emphysema,  the  efforts  at  breathing  often  assume  the 
most  extraordinary  intensity ;  the  thoracic  movements  are 
greatly  exaggerated,  the  muscles  of  the  neck  stand  out  with 
great  distinctness,  the  patient  sits  up  or  even  stands,  and 
sometimes  clutches  at  objects  with  his  hands,  so  as  to  give 
the  muscles  greater  purchase.  The  excessive  action  of  the 
dilator  narium  is  often  a  valuable  index  of  this  laborious 
breathing,  especially  in  the  case  of  children  affected  with 
pneumonia  and  bi'onchitis. 

Similar  results  likewise  happen  when,  instead  of  obstruc- 
tion to  the  passage  of  the  air,  a  large  part  of  the  breathing 
surface  is  suddenly  cut  off  in  other  ways,  as  by  the  perfora- 
tion of  the  pleura  and  the  collapse  of  the  lung  from  pneumo- 
thorax, or  by  sudden  effusion  of  fluid  into  the  pleura,  or  even 
sudden  oedema,  hemorrhagic  condensation,  or  congestion  of 
the  lungs  ;  or  again,  a  similar  result  may  be  brought  about 
by  sudden  blocking  of  the  pulmonary  artery, — although  the 
air  may  enter  both  lungs  freely,  the  pulmonary  function  is, 
of  course,  impaired  by  such  an  obstruction.  This  element 
of  suddenness  is  of  great  importance  in  respect  of  dyspnoea, 
for  if  the  breathing  surface  be  cut  off  slowly,  the  respiration 
may  have  time  to  adapt  itself  to  its  altered  condition;  hence 
there  may  be  extensive  thrombosis  of  the  pulmonary  artery 
without  any  alarming  dyspnoea,  until  perhaps  a  fatal  dis- 
placement of  a  clot  takes  place  ;  or  pneumo-thorax  may  exist 
without  the  patient's  being  able  to  fix  a  probable  date  of  its 
occurrence, — the  collapsed  lung  having,  perhaps,  been 
rendered  practically  useless  from  some  previous  extensive 
disease  ;  the  whole  of  one  side  and  part  of  the  other  may  be 
full  of  fluid,  while  the  patient  has  scarcely  been  conscious  of 
breathlessness,  owing  to  the  very  gradual  increase  of  the 
effusion.  Tiie  element  of  suddenness  exists,  of  course,  in 
all  the  spasmodic  forms  of  laryngeal  and  bronchial  obstruc- 
tion. A  further  point  of  importance  in  connection  with  dysp- 
noea is  the  point  at  which  the  mechanical  impediment 
exists  ;  a  slight  oedema  of  the  glottis  may  cause  suftbcation, 
and  an  exudation  in  the  trachea  or  large  bronchi  gives  rise 
to  the  most  distressing  dyspnoea  from  the  large  respiratory 
area  thus  involved. 

The  following  are  the  common  causes  of  dyspnoea,  arising, 
directly  or  indirectly,  in  a  mechanical  manner :  Inflamma- 
tions of  the  larynx,  oedema  and  spasms  of  the  glottis,  foreign 


260      DTSPNCEA,    PALPITATION,   THORACIC    PAIN. 

bodies  in  the  larynx  or  trachea  ;  diphtheritic  or  croupy  mem- 
branes in  the  larynx,  trachea,  or  bronchi ;  tumors  and  ab- 
scesses either  of  the  larynx  itself  or  pressing  on  it  or  on  the 
trachea  from  ■without  (especially  aneurisms,  cancers,  retro- 
pharyngeal abscess)  :  aneurisms,  glands  or  other  tumors  in 
the  chest  pressing  on  or  irritating  the  recurrent  laryngeal 
nerves  ;  spasmodic  or  nervous  asthma  ;  inflammatory  disease 
of  the  lungs,  bronchi,  and  pleural ;  dropsical  exudations  into 
the  pulmonary  tissue  or  into  the  pleura ;  pneumo-thorax ; 
extensive  consolidation,  collapse,  or  emphysema  of  the  lung; 
extensive  excavation  from  tubercular  disease,  abscess,  or 
gangrene ;  embolism  and  thrombosis  of  the  pulmonary  artery  ; 
and  pressure  on  the  chest  from  below,  from  abdominal  dis- 
tension or  tumors  of  any  kind.      (Compare  next  section.) 

Cardiac  dyspncea,  or  cardiac  asthma,  as  it  is  sometimes 
called,  may  be  explained  in  certain  cases,  or  to  some  extent, 
on  mechanical  principles.  For  example,  a  somewhat  move- 
able thrombosis  in  the  right  side  of  the  heart  may  play  a 
similar  part  to  that  of  a  plug  in  the  pulmonary  artery,  and 
incompetency  of  the  valves  or  obstruction  of  the  orifices,  if 
extreme,  may  retard  the  circulation  through  the  lungs,  and 
so  impair  their  function  ;  or  again,  the  lungs  may  be  involved 
through  the  heart, — pulmonary  infarctions,  bronchitis,  con- 
gestion or  oedema  of  the  lung,  and  pleuritic  effusion,  may  all 
have  a  cardiac  origin.  But  cardiac  dyspnoea  is  often  too 
extreme  or  too  spasmodic  and  transitory  to  be  readily  ex- 
plained on  such  mechanical  grounds.  Clinically,  we  must 
accept  as  a  fact  the  frequent  occurrence  of  the  most  extreme 
forms  of  cardiac  dyspnoea,  apart  from  any  of  the  mechanical 
explanations  or  structural  changes  just  suggested. 

Orthojinoea — the  assumption  of  the  upright  posture  for  the 
purpose  of  getting  breath — is  one  of  the  great  features  of 
cardiac  dyspnoea.  But  in  cases  with  effusion  in  the  pleurae, 
and  even  in  oedema  or  congestion  of  the  lung  and  bron- 
chitis, the  patient  sometimes  has  a  considerable  tendency  to 
sit  up  for  breath.  When,  however,  this  symptom  is  strongly 
marked,  we  must  always  suspect  the  cardiac  origin  of  the 
illness,  or  the  presence  of  some  cardiac  complication ;  and 
this  suspicion  gains  in  strength  if  there  be  little  or  no  pul- 
monary mischief  present.  Thoracic  aneurism  is  to  be  classed 
with  cardiac  disease  in  this  respect.  Affections  of  the  peri- 
cardium, and  adhesions  of  this  membrane,  likewise,  give 
rise  frequently  to  orthopnoea,  although  simple  rheumatic 
pericarditis  may  exist  without  this  symptom.     All  forms  of 


ORTHOPNCEA — HURRYING    AND    CLIMBING.       261 

carclific  disease — those  iuvolving  the  size  of  the  heart-,  the 
tissue  of  the  walls,  the  orifices,  and  the  valvular  structures — 
may  give  rise  to  orthopnoea.  The  cardiac  element  in  the 
dyspnoea  may,  therefore,  be  a  secondary  or  additional  com- 
plication, appearing  in  the  course  of  pulmonary  emphysema, 
disease  of  the  kidney,  and  other  affections  ;  and  this  compli- 
cation may  give  rise  to  paroxysmal  exacerbations  in  the 
midst  of  a  chronic  state  of  dyspnoea  of  moderate  severity. 

Occasionally  the  orthopnoea  is  so  constant  and  so  extreme 
that  the  patient  cannot  even  lean  back  for  a  moment  without 
the  feeling  of  impending  suffocation,  and  he  can  only  get  a 
little  sleep  while  sitting  up  and  leaning  forward,  with  the 
head  resting  on  his  knees  or  hands,  or  on  a  table  before  him. 
Some  patients,  indeed,  resolutely  refuse  to  go  to  bed,  and 
may  sit  in  a  chair  for  weeks  and  months  together,  without 
once  even  attempting  to  lie  down.  These  extremely  per- 
sistent forms  of  orthopnoea  are  usually  associated  with  con- 
siderable dropsy. 

The  ex[)lanation  of  orthopnoea  is  plain  enough  when  there 
is  any  considerable  dropsy  or  pleuritic  effusion,  as  the  recum- 
bent posture  tends  in  such  cases  to  hamper  the  movements 
of  the  heart  and  lungs  from  the  gravitation  of  the  fluid. 
Further,  the  erect  posture  no  doubt  gives  the  respiratory 
muscles  much  better  purchase  in  their  play;  but  the  extreme 
difference  observed  in  many  cardiac  ctxses  cannot  be  reason- 
ably explained  in  any  such  way,  and  appears  to  depend  on 
some  nervous  cause. 

Great  increase  of  the  dyspnoea  on  hurrying  or  climhing 
agrees  with  orthopnoea  in  many  respects.  While  found  to 
some  extent  in  nearly  every  form  of  disease  which  impairs 
the  respiratory  function,  it  is,  like  orthopnoea,  specially 
marked  in  cardiac  affections  of  all  kinds.  A  patient  who  is 
able  to  walk  fairly  enough  and  at  a  moderately  good  pace  on 
a  level  road,  may  at  once  show  signs  of  dyspnoea  if  there  be  a 
continuous  although  gentle  ascent,  or  if  a  few  steps  have  to 
be  mounted  briskly;  hurrying  and  excitement  operate  in  the 
same  way:  all  of  these  influences  often  operate  together  in 
going  to  a  high-level  railway  station,  and  patients  not  unfre- 
quently  first  find  out  their  weak  point  under  such  circum- 
stances. 

Amongst  other  causes  which  operate  in  causing  dyspnoea 
under  similar  circumstances  may  be  mentioned  all  forms  of 
disease  disabling  the  lungs,  conditions  of  debility,  antemia, 


262      DYSPNCEA,   PALPITATION,    THORACIC    PAIN. 

&c.,  from  wliatcver  cause,  disease  of  the  kidneys,  dropsy, 
obesity,  pregnancy,  and  advancing  age. 

The  importance  of  this  feature  of  cardiac  disease  is  so 
great,  that  we  sometimes  set  our  patients  to  run,  or  even  to 
walk  gently,  up  one  or  two  stairs,  when  we  are  doubtful  ot 
there  being  any  affection  of  the  heart,  so  that  we  may  judge 
of  the  state  of  their  respiration  at  the  end  of  such  an  expe- 
riment. 

Palpitation  is  one  of  the  accompaniments  of  the  A^arious 
cardiac  symptoms  just  described,  but  it  may  also  form  the 
most  prominent  feature  of  such  complaints,  or  it  may  exist 
quite  apart  from  any  organic  affection  of  the  heart. 

When  due  to  cardiac  disease  it  has  a  tendency  to  very 
marked  exacerbations  in  connection  with  exertion  and  ex- 
citement, so  that  when  the  palpitation  occurs  frequently,  or 
chietly,  apart  from  these  influences,  and  when  it  is  not  readily 
induced  by  running,  or  by  climbing  hills  or  stairs,  we  have 
good  reason  to  hope  that  it  is  not  due  to  organic  disease. 

The  palpitation  of  cardiac  disease  is  frequently  associated 
with  an  undue  heaving  impulse,  and  there  is  usually  suffi- 
cient evidence  of  enlargement  or  of  valvular  disease,  on  a 
physical  examination  of  the  chest.  The  right  ventricle  fre- 
quently becomes  distended  or  displaced,  so  as  to  give  rise  to 
a  painful  sense  of  oppression  and  tenderness  from  the  exist- 
ence of  pulsation  in  the  epigastrium.  The  palpitation  from 
aneurisnial  disease  in  the  chest  must  be  considered  along 
with  that  of  cardiac  disease,  and  both  investigations  are 
conducted  by  similar  methods  ;  the  special  pulsations  of 
aneurismal  tumors  must  be  carefully  studied  as  to  the  site  of 
their  maximum  intensity  and  diffusion.  (See  Chapter  xvi., 
Part  2,  the  Physical  Examination  of  the  Heart.) 

But,  apart  from  these  organic  affections,  palpitation  is  very 
common  in  dyspepsia,  and  particularly  in  cases  with  much 
flatulent  distension  of  the  stomach.  In  such  cases,  especially 
when  complicated  with  hysterical  tendencies,  palpitation  may 
attain  its  most  extreme  degrees ;  and  in  these  tbrms  it  fre- 
quently proves  most  troublesome  while  the  patient  is  lying 
still  in  bed.  The  palpitation  of  dyspepsia  is  often  compli- 
cated Avith  intermission  or  irregularity  in  the  heart's  action, 
which  by  exciting  and  alarming  the  patient  is  apt  to  increase 
the  palpitation  still  further. 

Palpitation  is  one  of  the  leading  symptoms  of  .exophthal- 
mic goitre  :  it  is  then  associated  with   prominence  of  the 


PAIN    IN    THE    CHEST,  263 

eyeballs,  and  a  certain  fulness  or  enlargement  of  the  thyroid 
gland. 

Palpitation  of  the  heart  is  likewise  found  in  cases  of 
anaemia  and  general  debility  :  loss  of  blood  from  bleeding- 
piles  and  uterine  discharges,  for  example,  may  give  rise  to 
symptoms  liable  to  misinterpretation  in  this  way.  Palpita- 
tion and  epigastric  pulsation  sometimes  owe  their  origin  to 
the  practice  of  masturbation  or  other  forms  of  disorder  of 
this  class. 

Throbbing  of  the  ?,bdominal  aorta  is  not  uncommon  in 
debilitated  and  nervous  patients,  and  it  may  thus  simulate 
aneurism  in  this  situation,  but  a  careful  examination  of  the 
vessel  reveals  a  general  pulsation  and  fails  to  detect  any  en- 
largement or  any  true  tumor  of  tlie  artery.  Throbbing  of 
the  arteries  in  the  body  generally  may  likewise  be  felt  by 
patients  ;  this  may  arise  from  a  relaxed  state  of  their  vessels, 
apart  from  any  very  serious  affection,  although  such  general- 
ized pulsation  likewise  occurs  in  cases  of  aortic  valvular 
disease. 

Pain  in  the  Chest  exists  in  a  great  many  cases  of  dyspnoea, 
and  sometimes  constitutes  the  leading  feature  and  cause  of 
the  respiratory  distress  ;  this  is  especially  marked  in  cases 
of  pleurisy  and  pericarditis  during  the  stage  of  friction  ;  the 
movements  of  the  chest  are  actually  hampered  by  the  pain 
induced  by  them.  Similar  distress  is  sometimes  occasioned 
by  pleurodynia.  The  detection  of  friction  sounds  over  the 
heart  and  lungs  in  such  cases  explains  their  nature.  The 
pain  or  distress  in  dyspnoea  may,  on  the  other  hand,  arise 
simply  from  the  extremely  urgent  need  for  breath  which  the 
patient  experiences  ;  when  carried  beyond  a  certain  point, 
this  becomes  exquisitely  painful.  It  is  intensified  by  any 
coincident  palpitation  or  tumultuous  action  of  the  heart,  by 
certain  irregularities  or  imperfections  in  its  contraction, 
which  are  often  quite  discernible  by  the  patient,  and  these 
may  depend  not  merely  on  afi^ections  of  the  organ  itself,  but 
on  pressure  on  it  or  displacement  of  it  in  connection  with 
pleuritic  exudations,  pneumo-thorax,  thoracic  and  abdominal 
tumors,  excessive  dropsy,  or  even  by  distension  of  the  stom- 
ach and  bowels  in  cases  of  flatulence.  Many  cases,  of  course, 
have  a  complex  origin,  as  when  the  pain  of  a  perforation  in 
the  pleura  and  the  incipient  pleuritis  thus  induced  are  com- 
plicated with  the  extremely  urgent  dyspncca  resulting  from 
the  sudden  suppression  of  a  lung,  and  from  the  pressure  on 
the  heart   due  to   displacement  of  the  mediastinum.     The 


264      DYSPNCEA,   PALPITATION,    THORACIC    PAIN. 

combination  of  cardiac,  pericardial,  or  aneurismal  pains  with 
pleuritic  stitch  ;  and  the  association  of  these  with  the  most 
extreme  forms  of  dyspnoea  resulting  therefrom,  or  from 
oedema  or  consolidation  of  the  lung,  and  dropsy,  give  rise  to 
a  complex  distress  which  we  have  too  often  to  witness. 

A  certain  simulation  of  these  alarming  states  sometimes 
arises  in  connection  with  flatulence,  as  this  may  be  associ- 
ated with  pain  in  the  neighborhood  of  the  heart,  with  great 
paljiitation,  and,  especially,  in  hysterical  cases,  with  dyspnoea 
and  a  sense  of  choking.  Gouty,  neuralgic,  and  intercostal 
pains,  and  various  sensations  referable  to  uterine  irritation, 
may  also  occasionally  simulate  the  attacks  just  mentioned,  or 
even  those  included  in  the  next  paragraph. 

Angina  Pectoris  is  a  name  reserved  for  pain  obviously 
of  cardiac  origin  and  of  a -very  special  and  alarming  charac- 
ter ;  all  forms  of  cardiac  anguish,  although  not  presenting 
the  features  of  this  complaint  in  its  most  ty])ical  form,  have 
a  certain  resemblance  to  this  peculiar  suflTering.  "  Tbe  sub- 
jects of  angina  pectoris  report  that  it  is  a  suffering  as  sharp 
as  anything  that  can  be  conceived  in  the  nature  of  pain,  and 
that  it  includes,  moreover,  something  which  is  beyond  the 
nature  of  pain,  a  sense  of  dying."  (Latham.)  Others 
speak  of  a  feeling  of  constriction  of  the  thorax,  of  its  being 
an  "  inward"  pain,  or  of  its  resemblance  in  some  way  to  suf- 
focation. But  the  most  typical  angina  may  occur  without 
the  least  impediment  to  the  respiration,  and  the  patient  may 
feel  that  he  can  breathe  quite  freely.  The  pain  is  not  always 
centred  in  the  cardiac  region,  but  it  always  tends  to  the  left 
side  of  the  chest.  The  most  constant  of  all  the  features  of 
true  angina  is  an  indescribable  dread  of  immediate  death,  or 
perhaps,  as  has  been  said,  "  a  sense  of  dissolution,  not  a  fear 
of  it."  In  the  case  of  those  who  cannot  express  their  feel- 
ings accurately,  or  who  do  not  care  to  do  so  openly,  we  can 
sometimes  detect  in  their  countenances  the  evidence  of  a 
mortal  terror.  Along  with  the  above  there  is  often  a  tran- 
sient pallor  of  the  face,  and  likewise  an  associated  pain 
shooting  down  the  left  arm,  or  darting  across,  as  it  w^ere, 
from  the  heart  to  the  elbow,  or  there  may  be  numbness  and 
tingling  of  the  arm,  spreading  even  to  certain  fingers. 

The  most  typical  forms  of  angina  pectoris  may  exist  with- 
out any  lesion  recognizable  during  life,  and  the  dissections 
often  shoAv  merely  certain  changes  in  the  structure  of  tlie 
Avails,  especially  fatty  degeneration  of  the  fibres  and  atheroma 
of  the  coronary  arteries  ;  but  nearly  every  ibrm  of  cardiac 


CYANOSIS.  265 

lesion  may  be  found  in  cases  of  angina ;  and  in  like  manner 
we  may  say  that  indications  of  angina-like  attacks  may  fre- 
quently be  traced  as  forming  an  element  in  the  complicated 
suiferings  of  heart  disease. 

The  character  of  the  noise  heard  during  the  hreathless  at- 
tack often  guides  us.  The  presence  of  snoring,  or  of  very 
rough  and  loud-sounding  respiration,  is  found  in  cases  of 
tracheal  obstruction  (crou  |  ,  diphtheria), — the  variation  in 
the  sound  often  suggesting  a  gradually  diminishing  aperture 
for  the  passage  of  the  air.  Something  of  the  same  kind  of 
breathing  may  be  heard  where  abscess  behind  the  piiarynx, 
or  even  in  the  tonsils,  causes  much  dyspnoee.  When  the 
obstruction  consists  in  a  spasmodic  closure  of  the  glottis,  the 
sound  is  more  crowing  or  stridulous  (pertussis,  laryngismus 
stridulus,  irritation  from  foreign  bodies,  ulceration  or  tumor 
in  the  larynx,  or  pressure  on  the  laryngeal  nerves,  &c.).  If 
the  constriction  be  further  down,  whether  spasmodic  or  me- 
chanical, the  breathing  may  have  more  of  a  wheezing  or 
whistling  sound.  If  much  fluid  scretion  exist  in  the  trachea 
and  larger  bronchi,  gurgling  sounds  may  be  loudly  heard. 
But  some  of  the  most  severe  forms  of  dyspnoea  and  gasping 
respiration  may  exist  without  noisy  respiration,  as  in  embol- 
ism of  the  pulmonary  artery,  and  rapid  effusion  into  the 
pleura  or  pericardium.  In  cardiac  and  aneurismal  dyspncea, 
the  presence  of  noisy  respiration  will  depend  on  the  nature 
of  the  pulmonary  or  laryngeal  complications. 

Lividity  or  duskiness  of  the  face  (Cyanosis)  is  a  feature 
in  dyspncea  requiring  careful  attention ;  in  extreme  forms  a 
similar  condition  can  sometimes  be  recognized  also  in  the 
fingers  and  other  parts.  All  diseases  or  accidents  interfering 
with  the  entrance  of  air  to  the  lungs,  or  with  the  efficiency 
of  the  respiratory  function,  may  produce  cyanosis.  A  tinge 
of  lividity  can  often  be  detected  along  with  the  febrile  flush 
of  pneumonia,  of  phthisis,  and  of  acute  tuberculosis,  espe- 
cially if  these  diseases  be  extensive.  A  certain  degree  of  it 
is  habitual  in  all  serious  forms  of  acute  bronchitis  ;  in  this 
latter  complaint,  in  children,  the  blue  color  of  the  face  is  an 
indication  of  considerable  gravity.  In  attacks  of  bronchitis 
supervening  on  extensive  emphysema,  lividity  is  habitual, 
and  often  excessive.  In  extreme  pleuritic  effusion,  likewise, 
lividity  indicates  the  gravity  of  the  condition.  In  extensive 
excavation  or  destruction  of  the  lung,  and  also  in  pneumo- 
thorax, lividity  is  often  very  marked.  In  cardiac  disease  of 
nearly  every  form  lividity  is  apt  to  appear,  giving,  perhaps, 
23 


266      DYSPNCEA,   PALPITATION,    THORACIC    PAIN. 

a  dusky  flusli  on  the  cheeks  ;  this  may  be  so  habitual  as  to 
lead  to  changes  in  the  tissues  (induration  and  even  inflam- 
mation). If  the  cardiac  disease  involves  the  tricuspid  valve, 
more  extreme  lividity  may  take  place.  In  malformations  of 
the  heart,  and  defects  permitting  the  communication  of 
blood  from  the  right  to  the  left  side  directly,  extreme  lividity 
usually  exists  ;  in  infancy  this  may  often  be  seen  to  come 
on  during  crying,  or  at  certain  times  only,  owing,  no  doubt, 
to  the  varying  efficiency  with  which  the  foetal  orifices  are 
closed.  The  term  "  Morbus  C-iKruleus"  is  applied  to  this 
condition.  The  most  extreme  cyanosis,  however,  may  exist 
from  such  congenital  causes  without  the  least  dyspnoea. 
Amongst  other  causes  of  lividity,  not  especially  referred  to 
in  the  above,  may  be  mentioned  cholera  during  the  stage  of 
collapse,  and  the  cases  of  inhalation  of  gases  Avhich  are  not 
adapted  for  respiration  (nitrous  oxide,  chloroform  vapor, 
carbonic  acid,  &c.). 

Altered  Rhythn  of  the  Breathing ;  Nervous  and  Renal 
Dysjjnoea. — Alterations  in  the  rhythm  of  the  respiration 
sometimes  occur.  In  health,  the  breathing,  although  regular 
and  rhythmical  on  the  whole,  frequently  presents  an  occa- 
sional inspiration  of  greater  depth  than  usual,  a  i'act  of  which 
we  have  frequently  to  avail  ourselves  in  the  auscultation  of 
young  children.  But  very  mai'ked  alterations  in  the  respi- 
ratory rhythm  are  found  in  certain  cases  of  cardiac  disease 
(especially  dilated  and  fatty  heart),  and  sometimes  in  cere- 
bral affections,  or  even  in  certain  fevers  where  cerebral  symp- 
toms supervene.  The  breathing  referred  to  is  sometimes 
named  "  suspirious"  or  "  sighing,"  and  in  slight  forms  may 
consist  of  a  few  quick  gasps,  or  deep  sighing  inspirations, 
followed  by  a  period  of  slow  and  shallow^  respiration,  or  by  a 
very  temporary  suspension  of  the  process.  This  form  of 
breathing  may  be  associated  with  attacks  of  "  angina  sine 
dolore"  (Gairduer),  as  manifested  by  the  look  of  anguish 
and  general  distress  depicted  on  the  countenance  of  cardiac 
patients,  without,  it  may  be,  any  very  definite  pain.  This 
suspirious  respiration  is  often  present,  likewise,  in  very  vari- 
able degree,  in  some  cases  of  cerebral  disease,  and  also  in 
the  course  of  fevers  where  cerebral  symptoms  have  arisen. 
In  its  most  marked  character  it  is  spoken  of  as  the  Cheyne- 
Stokes  Res]}}' rati 071.  ''  It  consists  in  the  occurrence  of  a 
series  of  inspirations  increasing  to  a  maximum,  and  then 
declining  in  force  and  length  until  a  state  of  apparent  apnoea 
is  established.     In  this  condition  tlie  patient  may  remain  for 


CIIEYNE-STOKES    RESPIUATION.  26Y 

such  a  length  of  time  as  to  make  his  attendants  believeLthat 
he  is  dead,  when  a  low  inspiration,  followed  by  one  more 
decided,  marks  the  commencement  of  a  new  ascending  and 
then  descending  series  of  inspirations"  (Stokes).  This  ex- 
treme form  is  chiefly  characteristic  of  fatty  degeneration  of 
the  heart's  fibres.  Some  profess  to  distinguish  between  the 
''  Cheyne-Stokes  Respiration"  and  the  sighing  or  cerebral 
respiration  just  referred  to,  but  the  difference  seems  to  be 
one  of  degree  rather  than  of  absolute  quality.  In  any  case 
they  present  sufficient  resemblance  to  be  classed  together  in 
this  section. 

Labored  respiration  constitutes  a  common  feature  in  cere- 
bral apoplexy,  dating  sometimes  from  the  very  beginning  of 
the  attack,  in  the  severe  forms  with  deep  unconsciousness ; 
appearing  in  the  course  of  a  day  or  two  in  the  cases  which 
begin  in  a  less  alarming  way  although  advancing  towards 
death.  This  disturbance  of  the  respiration  is  probably  due 
in  part  to  the  direct  affection  of  the  pneumogastric  and  other 
nerves,  but  in  the  later  developed  cases  the  lungs  also  no 
doubt  become  involved  to  some  extent  from  the  unconscious 
and  paralyzed  condition  of  the  patient.  In  the  unconscious 
period  after  convulsion  fits  the  same  state  of  the  breathing 
may  be  present. 

Nervous  dysjjncea,  however,  may  occur  in  a  marked  form 
apart  from  any  serious  nervous  lesion,  and  quite  apart  from 
any  evidence  of  the  respiratory  or  circulatory  organs  being 
diseased.  Such  attacks  are  found  chiefly,  if  not  exclusively, 
in  women,  and  are  usually  complicated  with  hysteria.  Allied 
to  this  is  the  dyspnoea  sometimes  found  in  the  earlier  months 
of  pregnancy,  where  no  sufficient  explanation  can  be  afforded 
by  the  abdominal  distension  ;  indeed  it  may  pass  off  as  the 
abdomen  becomes  larger. 

Renal  dyspnoea  may  show  itself  as  an  early  symptom  of 
the  disease,  appearing  very  readily  on  exertion  ;  but  a  more 
extreme  form  of  breathlessness,  resembling  an  asthmatic 
attack,  appears  sometimes  in  affections  of  the  kidney  apart 
from  oedema,  cardiac  complications,  or  the  other  influences 
already  discussed. 

Before  any  negative  conclusion  can  be  arrived  at  warrant- 
ing the  diagnosis  of  nervous  or  renal  dyspnoea,  and  before 
any  diagnosis  of  one  form  of  dyspnoea  to  the  exclusion  of 
others  can  be  safely  made,  the  most  careful  exploration  of 
the  respiratory  and  circulatory  organs  must  be  undertaken, 
and  the  features  of  the  whole  case  must  be  viewed  from 


268  couaii. 

various  aspects  and  even  perhaps  watched  for  some  time  in 
its  various  phases  (see  Introductory  Remarks,  p.  256). 

COUGH. 

Cough  is  a  leading  symptom  in  many  diseases ;  it  some- 
times constitutes  the  chief  complaint  of  the  patient,  but  in 
other  cases  we  have  to  inquire  very  particularly  as  to  its 
presence.  In  all  cases  of  dyspnoea  and  thoracic  disease  the 
indications  afforded  by  its  absence,  or  by  its  special  charac- 
teristics when  it  is  present,  must  be  regarded  as  most  im- 
portant. Occasionally  it  is  so  slight,  and  the  patient  has 
become  so  much  accustomed  to  it,  that  it  is  only  when  at- 
tention is  specially  directed  to  it  that  its  existence  is  noticed ; 
in  such  cases  those  who  live  with  the  patient  can  often  give 
us  more  reliable  information  than  the  patient  himself.  Such 
slight  forms  of  cough,  occurring  chiefly  in  the  morning,  may 
constitute  one  of  the  early  symptoms  of  phthisis.  Although 
a  very  constant  indication  of  pulmonary  affections,  cough  is 
occasionally  absent  even  in  serious  and  advanced  disease  of 
the  lungs,  so  that  the  mere  absence  of  this  symptom  is  no 
security  for  the  soundness  of  these  organs.  Moreover,  ex- 
tensive pleuritic  effusions  frequently  become  developed  with- 
out any  warning  from  this  symptom. 

In  the  investigation  of  cough  we  inquire  whether  it  seems 
dry  or  moist,  and  what  kind  of  expectoration,  if  any,  is 
brought  up;  if  the  cough  is  loud  and  clanging,  or  with  a 
barking  or  brassy  sound,  associated  with  hoarseness,  or  with 
imperfection  in  the  closure  of  the  glottis ;  if  there  is  a  sense 
of  constant  irritation  with  the  cough,  or  if  the  act  of  cough- 
ing seems  to  clear  away  some  obstruction ;  if  it  comes  in 
paroxysms,  or  if  it  is  more  persistent  and  regular  in  its  oc- 
currence ;  if  it  comes  on  at  particular  times,  as  on  going  to 
bed  at  night  or  getting  up  in  the  morning,  or  on  passing 
into  a  colder  atmosphere,  or  on  speaking;  if  it  is  set  up  by 
any  special  posture,  as  by  lying  on  the  back,  or  on  the  one 
side  as  compared  with  the  other;  if  it  is  habitual  in  winter, 
disappearing  or  getting  much  less  in  summer  time ;  if  it  is 
associated  with  retching,  or  terminated  by  an  act  of  vomit- 
ing ;  and  if  there  is  stridulous  or  crowing  inspiration  asso- 
ciated with  it.  The  duration  of  the  cough,  the  site  and 
character  of  the  pain,  if  any,  the  presence  of  dyspnoea,  the 
special  character  of  the  sputum,  and  the  examination  of  the 
chest,  constitute  important  points  in  the  further  inquiry. 


PAROXYSMAL    COUGH.  269 

The  presence  of  cough  always  suggests  the  existence  of 
some  kind  of  disease  in  the  respiratory  tract,  but  we  know 
that  a  cough  may  be  induced  in  a  reflex  manner.  Thus 
aneurismal  or  glandular  tumors  in  the  mediastinum  may 
produce  spasmodic  or  paroxysmal  attacks  of  coughing ; 
syringing  the  ears  has  been  known  to  produce  coughing,  and 
probably  certain  forms  of  disease  in  this  situation  may  like- 
wise do  so;  in  hysterical  attacks,  and  in  pregnancy,  cough 
may  be  set  up  apart  from  any  disease  of  the  air  passages ; 
and  certain  forms  of  gastric  irritation  may  likewise  produce 
a  reflex  cough.  But  "  stomach  coughs"  and  the  other  forms 
of  reflex  cough  are  not  to  be  too  readily  accepted ;  the  most 
careful  examination  of  the  chest  must  first  be  made  in  all 
such  cases. 

In  Pertussis  (whooping-cough)  the  violent  cough  is  the 
chief  fact ;  there  is  usually,  however,  more  or  less  bronchial 
catarrh  also,  the  signs  of  which  can  generally  be  found  in 
the  lungs,  especially  if  we  listen  just  before  a  paroxysm  of 
coughing.  This  disease  is  rare  above  the  age  of  puberty ; 
it  is  infectious,  and  one  attack  usually  protects  the  patient 
from  subsequent  ones,  but  a  relapse  after  an  interval  of  free- 
dom for  some  weeks  or  months  is  not  uncommon.  These 
points  are  often  important  in  the  diagnosis.  In  the  early 
stage  the  cough  is  characterized  by  a  rapid  succession  of  ex- 
piratory acts,  without  much  pause  between  them,  so  that  the 
child's  face  rapidly  becomes  red;  this  peculiar  cough  comes 
in  paroxysms,  and  may  often  be  recognized  as  whooping- 
cough  by  an  experienced  ear  even  before  the  "  wlioop"  be- 
comes developed.  This  "whoop"  is  a  long-drawn  crowing 
sound,  coincident  with  the  inspiratory  act  wiiich  follows  the 
violent  series  of  coughs;  this  peculiar  sound  is  due  to  the 
passage  of  the  air  through  a  glottis  partially  closed  by  spasm. 
This  sound  may  be  loud  and  resounding,  or  it  may  be 
somewhat  choked  or  inaudible  or  quite  suppressed,  through 
excess  of  the  spasm.  The  child's  face,  by  its  blueness,  indi- 
cates the  gravity  of  these  fits  ("dumb  kinks").  To  the 
violent  paroxysmal  acts  of  coughing  the  name  "kinks"  is 
applied  by  some  mothers,  the  term  "  whooping"  being  re- 
served for  those  attacks  associated  with  "  crowing."  Cer- 
tain cases  pass  through  their  course  without  a  single  paroxysm 
of  "  crowing"  being  heard,  but  this  is  quite  exceptional. 
The  paroxysm  of  whooping-cough  is  often  terminated  by 
vomiting,  the  contents  of  the  stomach  coming  away  freely, 
and  in  many  cases  there  is  much  glairy  and  sticky  phlegm 

23* 


270  COUGH. 

also.  The  cough  sometimes  produces  bleeding  from  the 
nose,  ears,  and  eyes ;  great  suffusion  and  much  swelling  of 
the  eyes  and  fiice  are  common.  All  degrees  of  feverishness 
and  prostration  are  found  in  whooping-cough,  but  these  are 
usually  present  to  a  serious  extent  only  in  those  cases  asso- 
ciated with  much  catarrh,  with  diarrhoea,  or  other  complica- 
tions. In  the  intervals  of  the  paroxysms  the  child  seems 
often  perfectly  well.  In  the  diagnosis,  the  presence  of  an 
ulcer  on  the  frenum  lingua?  is  sometimes  of  considerable 
value;  it  appears  in  about  one  half  of  the  cases  soon  after  the 
paroxysmal  cough  has  been  fully  developed.  It  only  occurs 
in  those  who  have  incisor  teeth  in  the  lower  jaw,  so  that  it 
seems  to  have  a  purely  mechanical  origin.  This  ulcer  dis- 
appears with  the  diminution  of  the  cough.  The  paroxysmal 
cough  of  pertussis,  and  also  the  ulcer,  may  both  disappear 
"with  the  advent  of  serious  complications  (pneumonia,  con- 
vulsions, &c.)  and  may  reappear  after  these  have  passed 
away. 

A  crowing  inspiration,  somewhat  resembling  that  of  per- 
tussis, is  found  in  young  children  in  the  disease  known  as 
Laryngismus  stridulus :  it  is  due,  as  in  whooping-cough,  to 
spasm  of  the  glottis,  but  there  is  not  usually  any  special  cough 
in  Laryngismus.  This  disease  affects  rickety  children  in  par- 
ticular, and  is  frequently  associated  witli  attacks  of  general 
convulsions. 

Another  disease  associated  with  paroxysmal  cough  and 
crowing  is  that  known  as  Broncldal  phthisis,  due  to  tuber- 
cular affections  of  the  bronchial  glands.  This  often  bears  a 
close  resemblance  to  pertussis.  The  history  of  a  former  at- 
tack of  whooping-cough,  or  the  absence  of  any  evidence  of 
infection  received  or  transmitted,  and  the  chronicity  of  the 
complaint  frequently  assist  in  the  discrimination  of  this  dis- 
ease. 

In  Measles  and  Injiuenza  tlie  disease,  although  of  a  gen- 
eral nature,  falls  specially  on  the  organs  of  respiration,  and 
manifests  itself  by  cough  among  otlier  symptoms.  A  certain 
degree  of  pulmonary  catarrh  with  more  or  less  cough  is  pre- 
sent in  many  other  febrile  diseases. 

Irritation  of  the  throat  or  glottis  may  set  up  a  cough  in  a 
mechanical  way.  Thus  the  passage  of  fluids  or  solids  towards 
the  larynx  may  produce  violent  coughing,  which  tends  to  per- 
sist for  some  time  after  the  irritation  is  removed.  Greedy 
sucking  on  the  part  of  a  thirsty  infant,  the  trickling  down  of 
fluids  from  tlie  posterior  nares  (post-nasal  catarrh,  &c.),  and 


IRRITATION    IN    LARYNX    AND    BRONCHI.         271 

the  presence  of  an  elongated  uvula  may  be  mentioned  under 
tills  heading.  Certain  irritating  gases,  such  as  chlorine  and 
sulphurous  acid,  likewise  produce  violent  paroxysms  of  cough- 
ing in  healthy  persons;  and  in  those  rendered  specially  sus- 
ceptible from  disease  in  tlie  larynx  or  bronchi,  the  passage 
from  a  hot  to  a  cold  atmosphere,  or  the  reverse,  may  set  up 
violent  fits  of  coughing. 

A  Laryngeal  cough  is  often  loud,  clanging,  and  very  fre- 
quent and  irritating;  it  may  also  be  hoarse  and  imperfect 
(see  p.  300).  Ulceration  and  thickening  of  the  mucous  mem- 
brane may  give  rise  to  both  forms  ;  the  ulceration  is  often 
associated  with  tubercular  or  syphilitic  disease.  Tumors, 
oedema,  abscesses,  &c..  operate  in  the  same  way.  Direct 
pressure  on  the  trachea  by  'in  aneurismalor  malignant  tumor 
may  give  rise  to  a  croupy  quality  of  the  cough,  usually  asso- 
ciated with  stridulous  respiration.  In  paralytic  atfections  of 
the  larynx  the  cough,  like  the  voice,  is  usually  hoarse.  All 
forms  of  laryngeal  irritation  are  apt  to  give  rise  to  spasms  of 
the  glottis.  This  imparts  a  stridulous  character  to  the  inspi- 
ratory acts  associated  with  the  cough.  In  laryngeal  ulcera- 
tion streaks  of  blood  are  common  in  the  sputum,  but  the 
expectoration  is  seldom  profuse.  An  examination  of  the 
larynx  by  the  laryngoscope  (see  Chapter  x.),  and  of  the 
chest,  for  any  signs  of  tubercular  disease,  aneurism,  or  tho- 
racic tumor,  and  an  inquiry  as  to  the  presence  of  constitu- 
tional syphilis,  are  all  very  important  points  in  such  cases. 
A  barking,  brassy  cough  is  common  in  croup,  and  also  in 
diphtheria,  when  it  attacks  the  larynx  and  trachea.  Along 
with  this  quality  of  the  cough  we  have  noisy  breathing,  which 
can  usually  be  recognized  at  once  as  due  to  obstruction  in  the 
upper  part  of  the  air  passages.  An  examination  of  the  fauces 
may  reveal  the  white  })atche3  of  diphtheritic  exudation,  the 
extension  of  which  to  the  larynx  has  caused  the  obstruction. 
Wlien  the  disease  begins  in  the  trachea  there  is  usually  a  pe- 
riod of  illness  for  a  day  or  two  days,  associated  with  high 
fever,  prior  to  the  appearance  of  any  alarming  obstruction  to 
the  breathing.  Very  sudden  attacks  of  hoarse,  croupy  cough, 
coming  on  in  the  night,  and  subsiding  quickly  on  the  use  of 
warm  baths,  emetics,  etc.,  are  usually  due  to  a  form  of  laryn- 
gitis. (To  this,  and  also  to  Laryngismus  stridulus,  the  name 
"False  croup"  is  sometimes  applied.)  Croup  and  laryngeal 
diphtheria  cannot  be  separated  clinically  ;  an  attack  of  appa- 
rently typical  croup  may  occur  amidst,  or  seem  to  give  rise  to 


272  COUGH. 

undoubted  diphtheria.  Occasionally  shreds  of  membrane  ai*e 
expectorated  or  coughed  up  in  these  affections. 

Foreign  bodies  of  the  most  diverse  kinds  sometimes  pass 
into  the  trachea  or  into  one  of  ihe  bronchi ;  in  the  act  of 
entering  violent  and  paroxysmal  cough  is  set  up,  but  as  this 
may  gradually  subside  much  doubt  may  remain  as  to  whether 
the  foreign  body  was  swallowed,  or  Avhether  it  actually  passed 
down  into  the  trachea.  In  the  latter  case,  the  cough  usually 
continues  to  recur  in  paroxysms  of  varying  intensity,  and 
severe  or  fatal  spasm  of  the  glottis  may  supervene.  In  cases 
of  this  kind,  assuming  a  chronic  form,  the  cough  may  simu- 
late that  of  advancing  phthisis  ;  and  emaciation,  sweating, 
and  feverishness  may  all  add  to  the  resemblance  ;  subsequent 
dilatation  of  the  bronchi,  the  formation  of  cavity,  and  the 
secretion  of  pus  may  add  further  to  the  difficulties.  Indeed, 
tlie  discrimination  may  be  impossible  ;  but  when  the  history 
clearly  points  to  the  accident  in  swallowing  as  the  date  of  the 
appearance  of  the  cough,  when  the  family  history  is  good, 
and  the  pliysical  signs  of  phthisis  equivocal  in  any  way,  the 
possibility  of  this  form  of  disease,  and  the  question  of  surgi- 
cal exploration  or  interference  must  be  entertained. 

In  all  varieties  of  bronchial  and  pulmonary  disease  cough 
is  almost  always  present,  sometimes  in  slight  forms,  some- 
times in  suffocative  paroxysms  of  great  severity.  In  the 
pneumonia  of  children,  however,  it  is  seldom  present  in  the 
early  stage.  In  pericarditis  also  cough  is  often  a  trouble- 
some symptom ;  it  has  sometimes  a  hoarse  quality.  In 
pleurisy,  apart  from  complications,  there  is  sometimes  an  ab- 
sence of  cough  ;  but  pleurisy  frequently  accompanies  pneu- 
monia and  phthisis,  and  when  cough  is  then  present,  it  is 
often  extremely  painful — the  pain  being  referred  to  the  site 
of  the  pleuritic  inflammation.  Similarly  pain  with  the  cough 
occurs  notably  in  pericarditis  and  peritonitis,  and  also  in 
rheumatic  affections  of  the  muscles.  In  bronchitis  the  pain 
associated  with  the  cough  is  usually  substernal.  The  cha- 
racter of  the  expectoration,  the  physical  examination  of  tlie 
chest,  and  the  previous  history  must  be  relied  on  in  seeking 
to  ascertain  the  cause  of  cough  in  pulmonary  disease.  It 
must  be  remembered  that  cardiac,  aneurismal,  or  renal  affec- 
tions may  constitute  the  primary  disease  of  which  the  pul- 
monary mischief  is  but  a  manifestation  or  complication. 


EXPECTORATIOX.  2t3 


EXPECTOEATlON. 


The  expectoration  of  liospital  patients  is  usually  preserved 
for  inspection  as  a  matter  of  routine.  Earthenware  spit- 
toons are  generally  employed,  but  glass  dishes  have  the  ad- 
vantage of  showing  the  character  of  the  expectoration  some- 
Avhat  better,  especially  if  it  is  abundant.  In  private  practice 
we  have  to  direct  the  patient  to  preserve  the  sputa,  when 
this  is  a  matter  of  importance,  as  in  pneumonia  and  cases  of 
haemoptysis.  Little  vessels,  soap  dishes,  or  articles  of  a 
similar  size,  are  generally  at  hand  in  the  bed  room,  and  can 
be  used  for  this  purpose.  When  the  quantity  is  large  we 
have  sometimes  to  pour  the  contents  slowly  from  one  vessel 
to  another,  so  as  to  judge  of  their  character  and  admixture; 
or  by  emptying  them  on  to  a  blackened  plate  we  may  be  able 
to  pick  out  little  pieces  for  more  ci-itical  examination.  While 
thus  emptying  the  contents  we  are  able  to  notice  any  fetor, 
or  the  peculiar  odor  of  gangrene,  if  these  be  present. 

We  describe  the  expectoration  as  to  its  quantity  in  the 
twenty-four  hours  ;  as  to  its  composition,  whether  mucous, 
purulent,  muco-purulent,  or  bloody ;  as  to  its  consistence, 
whether  thick  or  thin,  composed  of  separate  and  defined 
sputa,  or  more  homogeneous ;  whether  tenacious,  viscid, 
lluid,  or  frothy.  The  frothiness  may  show  itself  as  large  air 
bubbles,  or  these  may  be  so  minute  and  so  much  mixed  with 
the  mucus  as  to  require  close  examination.  Various  impuri- 
ties are  often  mixed  up  with  the  expectoration, — as  matters 
from  the  stomach,  pieces  of  food  from  the  mouth,  and  acci- 
dental particles  carried  in  from  the  air.  Coloring  matters 
suggestive  of  blood  may  be  derived  from  the  brown  crust  of 
bread,  from  wine,  from  tobacco  juice,  and  the  coloring  of 
sweet-meats. 

In  health  a  little  mucus  is  expectorated,  and  in  disease 
the  sputum  may  consist  chiefly  of  mucus.  In  smoky  towns 
this  is  very  apt  to  be  of  a  dark  color  from  the  presence  of 
floating  soot ;  and  in  the  case  of  miners,  from  similar  causes, 
the  expectoration  is  usually  black.  Occasionally,  however, 
the  black  color  is  derived  from  the  jiulmonary  pigment  in 
cases  with  breaking  up  of  the  lungs. 

Frothy  mucus,  sometimes  rather  watery,  is  often  expec- 
torated in  acute  bronchitis  and  oedema  of  the  lung.  Minute 
aeration  of  the  sputa  is  often  found  in  the  tenacious  mucus 
expectorated  in  pneumonia,  but  this  is  usually  rusty  or  dis- 
tinctly bloody.     (See  p.  275.) 


274  EXPECTORATION. 

Purulent  sputa  cannot  be  absolutely  separated  from  mu- 
cous sputa,  as  the  two  conditions  merge  into  each  otlier,  and 
an  intermediate  condition  is  often  named  "  muco-purulent." 
These  forms  of  expectoration  must  also  be  described  as  to 
their  frotliiness,  consistence,  color,  &c.  The  sputa  may 
consist  of  almost  pure  pus  ;  and  when  these  spread  out  so  as 
to  form  flat  masses  resembling  the  shape  of  pieces  of  money, 
they  are  called  "nummular"  ;  when  they  retain  a  spherical 
form  they  are  termed  "  globular."  Both  of  these  forms  are 
commonly  seen  in  cases  of  advanced  phthisis,  but  nummular 
sputa  may  often  be  found  in  chronic  bronchitis  also.  Puru- 
lent expectoi-ation  is  common  in  all  chronic  forms  of  catarrli 
affecting  the  respiratory  tract.  Very  profuse  expectoi'ation 
of  pus  (Bronchorrhoea),  usually  of  a  fetid  character,  may 
proceed  from  dilated  bronchi.  A  sudden  profuse  expectora- 
tion of  pus,  or  the  sudden  increase  of  it,  may  depend  on  the 
bursting  of  a  tubercular  vomica  or  of  an  intrapulmonary 
abscess,  or  it  may  be  due  to  the  opening  of  a  collection  of 
pus  in  the  pleura  into  a  bronchus,  or  to  the  opening  of  a 
hepatic  abscess  through  the  diaphragm  ;  or,  more  rarely,  to 
the  bursting  of  some  abscess  in  the  mediastinum  or  elsewhere. 
When  an  empyema  bursts  in  this  way  the  pus  expectorated 
is  usually  rather  fluid,  and  it  may  come  up  in  large  quanti- 
ties. The  signs  of  hydro-pneumo-thorax  usually  become 
developed  after  such  an  accident,  but  this  is  not  always  the 
case.  The  pus  from  a  pulmonary  abscess  may  or  may  not 
be  fetid  ;  possibly  it  may  have  a  gangrenous  odor  ;  its  quan- 
tity on  any  one  day  is  usually  moderate  (say  12—18  oz.), 
and  the  microscope  may  reveal  shreds  of  lung  tissue  in  great 
abundance,  and  in  some  cases  blood  crystals  are  also  present. 
Such  abscesses  are  sometimes  due  to  embolism  of  the  pul- 
monary artery.  Hepatic  abscess  usually  declares  its  presence 
by  symptoms  and  facts  pointing  to  the  liver  before  it  gets 
the  length  of  perforating  the  lung. 

Fibrinous  shreds  from  the  trachea  are  sometimes  expec- 
torated in  croup  and  diphtheria,  and  fibrinous  casts  of  the 
smaller  bronchi  may  occur  in  connection  with  Plastic  or 
Fibrinous  Bronchitis. 

Little  cheesy  masses  sometimes  come  from  pits  in  the  ton- 
sils ;  but  these,  and  also  calcareous  masses^  may  be  expec- 
torated in  cases  of  old  standing  phthisis.  Shreds  of  hydatids 
may  be  brouglit  up  in  connection  with  hydatid  cysts  of  the 
lung  and  also  of  the  liver.     (See  Fig.  42.) 

The  expectoration  of  Mood  (Haemoptysis)  is  always  a  most 


HEMOPTYSIS.  275 

important  fact.  Care  must  be  taken  to  avoid  errors-from 
the  presence  of  coloring  matter  accidentally  mixed  with  the 
sputum ;  the  microscope  may  here  be  called  in  to  discrimi- 
nate the  red  blood  corpuscles.  The  Guaiac  test  used  for 
urine  is  not  here  available.  But  even  when  we  are  sure  of 
the  presence  of  blood,  this  may  possibly  come  from  spongy 
gums,  as  many  persons'  gums  bleed  very  readily,  and  espe- 
cially if  they  are  sucked ;  or  the  blood  may  come  from  the 
nose,  trickling  down  the  posterior  nares,  even  when  none 
appears  from  the  nostrils  ;  or  the  blood  may  come  from  ulcer- 
ations, &c.,  in  the  throat  or  in  the  larynx.  The  mention  of 
the  sources  may  serve  to  direct  our  attention  in  scrutinizing 
the  source  of  the  bleeding.  Or,  again,  especially  in  profuse 
bleeding,  there  may  be  a  question  as  to  whether  it  comes 
from  the  stomach  (Ha^matemesis,  see  p.  312).  Blood  from 
the  lungs  is  usually  more  florid  and  more  frothy  than  that 
brought  up  from  the  stomach :  the  latter  is  usually  dark  and 
acid,  and  may  be  mixed  up  with  partially  digested  food. 
The  term  "  vomiting"  of  blood,  as  used  popularly,  signifies 
the  bringing  up  of  any  large  quantity  of  blood,  whether 
from  the  lungs  or  stomacli.  Even  when  it  comes  from  the 
lungs,  the  action  resembles  very  much  that  of  vomiting. 
Difficulties  in  the  diagnosis  may  arise  from  blood  from  the 
lungs  being  in  part  swallowed  before  it  is  vomited  up  again. 

When  the  blood  really  comes  from  the  lungs,  whether  it 
be  in  large  or  small  quantity,  it  is  always  a  serious  fact.  The 
least  grave  form,  perhaps,  is  the  presence  of  slight  streaks  in 
the  expectoration  in  connection  with  violent  fits  of  coughing, 
or  during  an  attack  of  moderately  acute  bronchitis. 

The  rusty  sputa  found  in  pneumonia  owe  their  color  to 
blood ;  in  some  cases  the  presence  of  blood  is  very  pronounced 
in  this  disease.  The  rusty  color  is  produced  by  the  very 
intimate  admixture  of  blood  with  the  mucus,  and  this  secre- 
tion is  usually  very  tenacious,  as  can  be  shown  by  turning 
the  vessel  upside  down  :  minute  air-bubbles  may  often  be 
seen  in  this  expectoration.  Tliis  rusty  expectoration  is  very 
important  in  the  diagnosis  of  pneumonia  from  pleurisy  and 
other  afi^ections,  although  it  is  occasionally  absent — notably 
in  the  case  of  children,  and  also  usually  in  the  pneumonic 
consolidations  of  typhus. 

Closely  allied  to  the  rusty  spit  of  pneumonia,  although 
often  more  distinctly  bloody  and  more  largely  aerated,  is 
that  of  valvular  heart  disease,  or  that  which  is  found  in 
minute  aneurismal  hemorrhages  into  the  trachea,  or  that  of 


276  EXPECTORATION. 

pulmonary  infarctions  clue  to  embolism  of  the  pulmonary 
artery.  This  last  form  arises  in  cases  of  heart  disease,  and 
also  in  diseases  characterized  by  a  tendency  to  venous  throm- 
bosis (child-birth,  &c.).  The  coexistence  of  pleuritic  friction 
with  evidence  of  pulmonary  consolidation  and  haemoptysis 
has  sometimes  been  noticed  in  cases  of  this  kind. 

Another  form  of  intimate  admixture  of  blood  assumes  a 
darker  color,  somewhat  resembling  prune  juice  :  this  occurs 
in  cases  where  the  blood  lingers  longer  in  the  pulmonary 
tissues ;  it  is  found  in  cases  of  chronic  pneumonia  going  on 
to  destruction  of  the  lung,  and  also  in  certain  cases  of  aneu- 
rismal  hemorrhage,  where  the  openings  are  so  minute  as  to 
leak  only  to  a  slight  extent. 

A  form  of  bloody  spit,  somewhat  resembling  the  appear- 
ance of  red  currant  jelly,  is  sometimes  seen,  and  is  regarded 
as  characteristic  of  pulmonary  cancer. 

Hemorrhage  from  the  lungs  may  occur  as  part  of  a  general 
hemorrhagic  tendency,  as  in  purpura  and  hemorrhagic  small- 
pox :  the  exact  appearance  of  the  blood  will  vary  according 
to  the  extent  and  situation  of  the  special  bleeding.  In  certain 
cases  of  irregular  or  suppressed  menstruation  the  discharge  is 
said  to  find  its  escape  occasionally  from  the  lungs.  This  idea 
of  "  vicarious  menstruation,"  hovs'ever,  must  always  be  re- 
garded with  the  gravest  suspicion,  especially  in  young  sub- 
jects, as  suppressed  menstruation  and  htemoptysis  afford 
strong  grounds  for  suspecting  pulmonary  phthisis  ;  this  doubt 
can  only  be  set  aside  by  careful  watching  over  a  lengthened 
period.  Large  hemorrhages  from  the  lungs  occur  in  phthisis 
both  in  its  earliest  and  its  latest  stages,  in  cardiac  affections, 
especially  in  diseases  of  the  mitral  orifice  and  valve,  and  in 
cases  of  thoracic  aneurism  bursting  into  the  trachea  or  bron- 
chi. With  regard  to  phthisis  the  profuse  hemorrhage  in  the 
early  stage  is  not  veiy  intelligible  ;  it  may  occur  Avhile  as 
yet  there  are  no  physical  signs  of  consolidation,  and  not  very 
unfrequently  there  is  even  an  absence  of  the  physical  signs 
we  would  expect  from  the  presence  of  blood  in  the  air  vesi- 
cles :  usually,  however,  some  moist  rales  can  be  heard.  (A 
slight  hfemoptysis  frequently  repeated  is  much  commoner,  of 
course,  in  phthisis  than  these  alarming  attacks.)  Large 
hemorrhages  in  the  late  stages  of  phthisis  are  usually  due  to 
the  giving  way  of  some  considerable  artery,  destroyed  pro- 
bably in  the  course  of  the  ulcerative  process.  Sometimes 
these  hemorrhages  are  due  to  the  rupture  of  an  aneurism  of 
the  pulmonary  artery.     These  aneurisms  form  in  old  phthi- 


MICROSCOPIC    EXAMINATION    OF    SPUTUM.        277 

sical  cavities,  and  frequently  give  rise  to  smart  liemorrhages, 
or  to  constant  staining  of  the  sputa  for  some  time  before  the 
fatal  haemoptysis  occurs. 

HiEmoptysis  from  heart  disease  may  be  inferred,  as  a  rule, 
when  valvular  disease  of  the  heart  is  discovered,  apart  from 
any  signs  of  aortic  aneurism.  The  large  hemorrhages  from 
rupture  of  aortic  aneurism  are  usually  almost  immediately 
fatal,  but  the  patient  may  rally  for  a  time.  Such  hemor- 
rhage is  generally  preceded  by  slighter  forms  of  bleeding,  but 
sometimes  a  profuse  haemoptysis  is  the  first  indication  of 
aneurismal  disease. 

3Iicroscopic  examination  of  the  sputum  is  useful  in  deter- 
mining the  presence  of  pus  and  blood  corpuscles,  the  presence 
of  booklets,  &c.  from  hydatids  (Fig.  42),  and  the  occurrence 
of  crystalline  forms,  such  as  cholesterine  and  blood-crystals. 
Scales  of  cholesterine  (Fig.  43)  are  found  in  the  sputa,  in 
some  of  the  cases  in  whicli  a  pleuritic  exudation  has  opened 
into  the  lung  :  they  may  just  possibly  occur  also  in  cases  of 
long-retained  secretions  within  the  lung  itself.  Brilliantly 
colored  blood-crystals  in  the  sputa  are  found,  at  times,  in 
connection  with  hemorrhagic  infarctions  which  have  gone  on 
to  abscess.  Various  forms  of  vegetable  growths  are  often 
found  on  microscopic  examination,  but  these  are  not  usually 
of  much  importance.  Fragments  of  pulmonary  tissue  are 
sometimes  so  abundant,  especially  in  cases  of  pulmonary  ab- 
scess, that  they  can  be  found  on  placing  a  drop  of  the  purulent 
expectoration  on  a  microscopic  slide,  without  preparation  of 
any  kind.  In  cases  of  phthisis,  however,  the  fragments  are 
not  so  numerous,  or  are  too  much  entangled  in  thick  pus  to 
be  found  in  this  way. 

Sometimes  by  picking  out  with  needles  little  fragments 
from  the  sputa,  we  may  hit  upon  pulmonary  tissue.  Another 
method,  recommended  by  Dr.  Fenwick,  consists  in  liquefy- 
ing the  pus  by  means  of  caustic  soda.  A  solution  containing 
about  twenty  grains  to  the  ounce  is  added  in  equal  volume 
to  the  expectorated  matter  brought  up  during  a  night ;  this 
is  cautiously  boiled  in  a  flask  or  flat  dish,  so  as  to  allow  of 
efficient  stirring  and  mixing:  the  mixture  is  just  boiled,  and 
if  still  not  sufficiently  liquefied  a  little  more  of  the  solution 
should  be  added.  Prolonged  boiling  and  too  much  alkali 
tend  to  dissolve  the  fibrous  tissue  searched  for,  and  so  must 
be  avoided.  The  liquefied  mixture  is  placed  in  a  cylindrical 
glass  vessel,  and  after  it  settles,  a  few  drops  of  the  sediment 
may  be  examined  with  the  microscope,  or  a  portion  of  the 
24 


2Y8 


EXPECTORATION. 


liquefied  material  may  be  placed  in  a  similar  vessel,  and 
three  or  i'our  volumes  of  water  added  to  it  so  as  to  assist  the 
precipitation  of  the  pulmonary  fragments. 

In  examining  the  sediment  a  few  drops  should  be  lifted  by 
means  of  a  dipping  rod  (not  drawn  to  a  point),  and  these 
should  be  placed  on  a  large  slide  or  shallow  cell ;  the  layer 
of  fluid  must  however  be  very  thin.  A  low  power  should  be 
used — an  inch  or  half-inch  objective — and  if  any  group  of 
fibres  resembling  the  arrangement  of  the  pulmonary  cells  can 
be  seen,  higher  powers  may  be  used  to  resolve  their  struc- 
ture. Occasionally  separate  yellow  elastic  fibres  can  also  be 
recognized  with  their  typical  curling  at  the  ends.  Tlie  pieces 
vary  much  in  size  :  sometimes  only  a  few  loose  fibres  can  be 
found.     (See  Fig.  29.) 


Fig.  29.— Luug  tissue  obtained  from  sputa  after  digestion  in  caustic  soda. 
(Drawn  by  Dr.  John  Wilson.) 

Several  things  tend  to  confuse  the  beginnej"  in  this  in- 
quiry. Portions  of  vegetable  tissue,  from  the  food  or  from 
accidental  admixture,  are  often  found,  as  they  resist  of 
course  the  caustic  action  of  the  soda;  their  cellular  structure 
sometimes  misleads.  More  misleading  still  is  the  appear- 
ance of  certain  vegetable  growths;  but  their  branching  and 
interlacing  fibres  usually  guard  us  from  error.  A  good  plan 
for  the  beginner  is  to  secure  some  pus  from  a  phthisical  cav- 
ity, at  a  post-mortem  inspection,  and  by  subjecting  this  to 
microscopic  examination  after  digestion  in  soda,  and  also 
without  any  such  preparation,  he  becomes  familiar  with  the 
appearances  searched  for,  apart  from  most  of  tlie  structures 
which  tend  to  confuse.     Fragments  of  pulmonary  tissue  arc 


HEMORRHAGES.  2T9 

found  in  cases  of  phthisis  and  in  cases  of  pulmonary  abscess  : 
their  presence  assists  sometimes  in  distinguishing  pus  vom- 
ited from  an  abscess  from  that  of  an  empyema  opening  into 
the  lung. 

HEMORRHAGES. 

In  the  investigation  of  a  case  of  anaemia,  and  in  conduct- 
ing certain  parts  of  other  inquiries,  we  have  sometimes  to 
ask  about  the  occurrence  of  any  serious  loss  of  blood.  Such 
losses  may  be  serious  from  their  great  severity,  or  from  their 
long  continuance.  It  is  often  necessary  to  enumerate  to  the 
patient  the  various  forms  of  hemorrhage,  as  otherwise  we 
may  fail  in  ascertaining  the  facts.  Thus  we  inquire  for  any 
excessive  bleeding  occurring  from  the  surface,  from  wounds, 
ulcers,  leech  bites,  &c.  In  the  case  of  women,  we  ask  about 
any  losses  of  blood  in  connection  with  abortions,  or  with 
childbirth ;  and  for  any  other  hemorrhages  from  the  womb 
(Menorrhagia,  Metrorrhagia).  Spitting  or  vomiting  of  blood, 
whether  from  the  lungs  or  stomach  (Hajmoptysis  and  Hffima- 
temesis)  and  bleeding  from  the  nose  (Epistaxis),  or  from 
the  gums,  can  scarcely  be  overlooked.  Passing  blood  from 
the  bowels,  and  the  bleeding  from  piles,  should  be  inquired 
for  separately,  and  the  change  of  color  in  the  blood,  giving 
rise  to  dark  or  tarry  motions  (Melsena),  should  be  explained 
to  the  patient.  Blood  in  the  urine  (Htematuria)  is  usually 
recognized  as  such  by  the  patient  if  very  profuse  and  long 
continued,  but  smaller  quantities  may  escape  notice ;  subcu- 
taneous hemorrhages  or  blotches,  and  purple  spots  may  also 
be  inquired  for. 

Most  of  these  forms  of  bleeding  are  discussed  under  their 
special  sections,  but  bleeding  from  the  nose  (Epistaxis)  re- 
quires some  special  notice  here.  Like  other  forms  of  bleed- 
ing, it  may  be  due  to  general  causes,  such  as  purpura,  &c. 
(see  p.  280),  this  form  of  hemorrhage  being  but  one  of  the 
manifestations. 

Epistaxis  also  occurs  in  connection  with  severe  headache, 
arisino-  either  from  functional  disturbance,  or  from  cerebral 
disease.  The  hemorrhage  is  followed  sometimes  by  consid- 
erable relief;  it  may  be  brought  on  in  some  persons  very 
readily  by  excitement  and  heated  rooms.  It  is  not  uncom- 
mon in  the  early  stage  of  enteric  fever,  and  it  also  forms  an 
early  symptom  in  certain  cases  of  cardiac  and  hepatic  disease 
of  various  kinds.     It  occurs  sometimes  also  in  renal  aflfec- 


280  HEMORRHAGES. 

tions.  Epistaxis  and  other  forms  of  liemon-liage  are  not 
uncommon  in  connection  with  disease  of  the  spleen.  Bleed 
ing  at  the  nose  often  arises  in  direct  connection  with  the 
violent  paroxysms  of  Avliooping-cough,  and  it  may  be  asso- 
ciated in  this  disease  with  bleeding  from  the  eyes  and  ears. 
Sometimes,  although  rarely,  this  bleeding  from  the  nose  is 
so  readily  excited  by  the  fits  of  coughing,  and  is  so  excessive, 
that  we  must  suppose  some  peculiarity  in  the  system  at  the 
time,  especially  as  this  proclivity,  after  lasting  for  a  while, 
may  pass  away,  altliough  the  fits  of  coughing  continue,  or 
even  become  more  violent.  Bleeding  from  the  nose  may  be 
from  one  nostril  only  or  from  both.  In  many  cases  the 
blood  goes  back  to  the  throat ;  and  it  may  be  swallowed  or 
brought  up  according  to  the  strength  or  the  position  of  the 
patient.  Slight  bleeding  from  the  nose  is  often  due  to  pick- 
ing the  nostril.  This  occurs  in  children  chiefly,  and  is  sugges- 
tive of  gastro-intestinal  irritation  from  worms,  diarrhoea,  «&;c. 

Amongst  the  general  catises  of  hemorrhage,  applying  to 
many  or  most  of  the  forms,  may  be  mentioned  purpura  hem- 
orrhagica and  hemorrhagic  smallpox.  Bleeding  at  the 
nose  often  arises  in  enteric  fever,  probably  from  general 
causes.  Intestinal  hemorrhage  is  mostly  due  to  the  local 
affection  in  this  disease.  In  relapsing  fever,  menorrhagia 
and  post-partum  hemorrhage  are  common  ;  and  floodings 
after  abortions  or  parturition  are  sometimes  most  alarming 
in  typhus  fever  and  smallpox. 

Scurvy  resembles  purpura  in  predisposing  strongly  to 
hemorrhage  from  the  gums  and  elsewhere,  and  also  from  the 
ulcers  which  arise  in  its  course.  The  hemorrhagic  diathesis 
(Hemophilia)  must  also  be  mentioned  here.  The  bleedings 
connected  with  this  state  may  be  spontaneous — apart  from 
any  obvious  injury,  but  more  commonly  they  arise  from 
slight  Avounds  or  pricks  ;  leech  bites  are  peculiarly  apt  to  be 
intractable.  Affections  of  the  joints  sometimes  appear  in 
young  subjects  in  connection  with  this  state,  or  during  an 
interval  of  its  suspension.  The  hemorrhages  from  chi'onic 
hepatic,  cardiac,  and  renal  disease  are  usually  determined 
by  local  conditions^— cardiac  disease  giving  rise  especially  to 
haemoptysis,  hepatic  disease  to  gastric,  intestinal,  or  hfemor- 
rhoidal  bleeding,  and  renal  disease  to  hasmaturia — but  a 
general  influence  can  also  be  traced  in  all,  from  their  ten- 
dency to  be  associated  with  small  subcutaneous  hemorrhages 
and  epistaxis.  Hemorrhage  under  the  conjunctiva  occurs  at 
times  in  renal   disease,  and  retinal  hemorrhage  is  a  well- 


EXAMINATION    OF    THE    BLOOD.  281 

known  complication.  Cei'ebral  hemorrhage  is  likewise  com- 
mon in  renal  disease,  especially  when  associated  with  cardiac 
hypertrophy. 

In  the  forms  of  splenic  enlargement  due  to  malarial  fevers 
and  other  causes,  and  in  the  diiferent  varieties  of  leukemia 
and  lymphatic  disease,  epistaxis  and  subcutaneous  hemor- 
rhages are  common. 

EXAMINATION  OF  THE  BLOOD. 

Apart  from  the  superficial  examination  of  the  blood  lost 
in  hemorrhages  of  various  kinds,  much  may  be  hoped  from 
an  elaborate  chemical  and  microscopic  investigation  of  sam- 
ples of  the  blood  in  different  forms  of  disease.  Hitherto 
comparatively  little  has  been  made  of  this  form  of  inquiry, 
but  indications  of  its  growing  importance  are  not  wanting. 
With  regard  to  the  chemical  department  of  this  subject  there 
are  two  great  difficulties.  "We  have  to  face  all  the  compli- 
cations of  one  of  the  most  difficult  departments  of  organic 
analysis,  wiiile  but  few  physicians  in  actual  practice,  if,  in- 
deed, there  be  any,  are  adequately  prepared  for  such  inves- 
tigations. The  works  of  Hoppe-Seyler  may  be  referred  to 
for  the  best  instructions  in  this  branch  of  chemistry.  But, 
further,  we  are  confronted  with  the  practical  difficulty  of 
obtaining  samples  of  blood  at  such  times  and  in  such  quan- 
tities as  chemical  analysis  demands  :  the  cessation  of  vene- 
section as  a  common  form  of  treatment  renders  this  scarcely 
possible.  While  this  practice  was  common,  attention  was 
much  directed  to  the  presence  or  absence  of  the  "  buffy 
coat"  in  the  blood  removed  by  bleeding,  an  appearance  so 
usual  in  the  blood  drawn  from  the  veins  in  inflammatory 
disease,  that  its  presence  was  founded  on,  in  doubtful  cases, 
as  an  indication  of  the  existence  of  inflammation.^ 

Occasionally,  even  now,  we  try  to  procure  small  quantities 
of  blood  for  experimental  or  diagnostic  purposes,  as  described 
in  the  section  on  gouty  joints  where  Garrod's  method  of 
detecting  uric  acid  is  dealt  with  in  detail  (p.  126). 

Minute  quantities  of  blood  for  microscopic  and  other  similar 
examinations,  are  always  obtainable,  without  detriment  to 
the  treatment,  of  whatever  kind  this  may  be :  fortunately  it 

1  This  subject  is  discussed  in  physiological  works.  See  espe- 
cially the  researches  on  the  coagulation  of  the  blood  by  Lister  and 
others. 

24* 


282  EXAMINATION    OF    THE    BLOOD. 

is  in  this  direction  tliat  the  most  distinct  advances  have  re- 
cently l)een  made  in  the  examination  of  the  blood  for  the 
purpose  of  diagnosis. 

The  presence  of  an  excessively  large  proportion  of  color- 
less corpuscles  in  a  drop  of  blood  drawn  from  a  patient  con- 
stitutes the  condition  now  known  as  Leukcemia.  This  con- 
dition in  its  most  striking  form  is  usually  associated  with 
evidence  of  changes  in  the  spleen  or  in  the  lymphatic  glands 
of  the  patient  (Splenic  and  Lymphatic  Leukaemia :  see  also 
p.  120).  But  the  relative  numbers  of  the  white  and  red 
corpuscles  vary  greatly  in  different  persons,  at  different  times, 
within  the  limits  of  health  ;  in  various  diseases  the  propor- 
tion is  likewise  seriously  disturbed,  so  that  much  care  is  re- 
quired in  formulating  a  diagnosis  based  on  an  apparent  in- 
crease of  the  white  corpuscles  ;  in  anaemic  conditions  and  in 
cancerous  affections,  in  particular,  the  white  corpuscles  are 
often  increased.  In  preparing  a  specimen  for  microscopic 
examination  we  usually  prick  the  skin  of  the  finger  suddenly 
by  means  of  a  sewing  needle,  and  occasionally  it  is  better  to 
produce  congestion  of  the  finger  beforehand  by  the  moderate 
compression  of  a  ligature.  We  place  the  drop  of  blood  on 
a  perfectly  clean  slide  and  apply  a  cover  glass,  taking  care  to 
avoid  the  soiling  of  the  glasses  by  any  exhalations  from  the 
skin  of  the  patient  or  of  the  observer,  and  also  avoiding  any 
pressure  likely  to  damage  the  corpuscles.  The  drop  of  blood, 
indeed,  may  with  advantage  be  received  on  the  under  sur- 
face of  the  cover  glass,  held  with  a  pair  of  forceps,  and  the 
cover  glass  may  then  be  slipped  very  gently  down  on  to  the 
microscopic  slide  ;  we  aim  at  having  just  enough  blood  to  fill 
the  space  between  the  two.  The  red  corpuscles  usually  tend 
to  run  into  rouleaux,  and  the  white  blood  corpuscles  may  gen- 
erally be  easily  recognized  from  the  difference  of  their  shape, 
their  somewhat  larger  size,  and  their  want  of  color ;  their 
granular  appearance  also  favors  their  recognition.  The  act- 
ual number  of  white  blood  corpuscles  visible  in  the  field  may 
then  be  counted,  and  in  noting  the  result  we  should  name 
the  power  of  the  microscope,  specifying  the  number  or  the 
focal  distance  of  the  objective  and  the  maker  of  the  instru- 
ment ;  or  we  may  attempt  to  estimate  the  proportion  of  the 
white  to  the  red  corpuscles  by  counting  both  in  a  given  part 
of  the  field,  noting  1 — 40,  1 — 20,  1 — 10,  or  1 — 2,  &c.,  as 
the  case  may  be.  "We  should  always  estimate  several  differ- 
ent microscopic  "  fields"  before  arriving  at  an  opinion,  and  it 
is  very  desirable  also  to  have  more  than  one  specimen  of 


COUNTING    THE    CORPUSCLES.  283 

blood  to  avoid  accidental  fallacies.  The  figures  named'above 
indicate  the  results  frequently  obtained  in  cases  of  disease  : 
the  normal  proportion  of  the  white  to  the  red  corpuscles  is 
very  much  less. 

But  such  methods  of  enumeration  are  confessedly  rough, 
and  very  subject  to  accidental  variations.  A  more  accurate 
determination  demands  the  actual  counting  of  the  corpuscles 
of  both  kinds  in  a  quantity  of  blood  of  known  volume.  In 
order  to  facilitate  this,  tubes  and  slides  have  been  devised  by 
Malassez  and  others.  A  capillary  pipette  (Potain's)  is  so 
constructed  as  to  allow  one  volume  of  blood  to  be  diluted 
with  a  hundred  volumes  of  a  10  per  cent,  solution  of  sulphate 
of  soda.  This  mixture  not  only  dilutes  and  facilitates  the 
subsequent  enumeration,  but  it  also  prevents  coagulation. 
Malassez  has  also  devised  a  flattened  capillary  tube  fixed  in 
a  microscopic  slide,  carefully  adjusted  to  indicate  a  definite 
cubic  capacity  for  a  given  length — these  relations  being 
marked  on  the  glass  slides  :  e.  g.,  400  micro-millimeters  re- 
present x-gV.^th  part  of  a  cubic  millimeter,  and  .500  represent 
yg^gyth  part,  as  determined  by  the  instrument-maker.  AVith 
such  an  arrangement  it  is  evident  that  all  we  require  is  some 
means  of  measuring  the  micro-millimeters  (each  of  these  is 
equal  to  xoVo^^^  P^^t  of  a  millimeter,  and  is  often  indicated 
by  the  Greek  letter  y.).  This  is  best  done  by  means  of  an 
ocular  micrometer,  divided  into  small  squares,  the  exact 
value  of  which  may  be  determined  once  for  all  by  a  stage 
micrometer,  an  adjustment  of  the  one  micrometer  to  the 
other  being  made  by  drawing  out  the  tube  of  the  microscope 
to  a  certain  point  which  may  then  be  marked  ;  we  can  thus 
make  the  divisions  of  the  ocular  micrometer  correspond  in 
some  definite  proportion  to  those  of  the  stage  micrometer. 
In  this  way,  by  counting  tlie  corpuscles  in  a  definite  number 
of  the  squares  we  can  estimate  their  actual  number  in  a 
definite  fraction  of  a  cubic  millimeter,  and  on  multiplying 
by  a  hundred,  for  the  dilution  used,  we  obtain  the  figure 
w^anted. 

Another  plan  is  to  use  the  same  method  of  diluting  the 
blood  (at  least  if  small  quantities  only  are  available),  but 
instead  of  using  the  special  slide  of  Malassez  just  described, 
Hayem  and  Xachet  employ  a  slide  having  a  glass  ring.  |th 
of  a  millimeter  in  depth,  cemented  on  its  upper  surface.  A 
drop  of  the  mixture,  not  enough  to  fill  the  cell  so  formed,  is 
placed  in  the  middle  of  the  ring,  and  a  perfectly  flat  cover 
glass  is  so  laid  on  that  the  drop  touches  and  adheres  to  it 


284  EXAMINATION    OP    THE    BLOOD. 

without  reaching  the  sides  of  the  cell.  If  a  square  area  of 
|th  of  a  millimeter  be  selected,  we  have  of  course  ith  of  a 
cubic  millimeter  of  diluted  blood  ready  for  our  enumeration 
by  means  of  the  ocular  micrometer  ruled  in  squares  as 
before.^ 

By  such  a  method  we  can  state  the  actual  number  of  white 
and  red  corpuscles  in  a  definite  volume  of  blood,  or  if  we 
prefer  doing  so,  we  can  give  the  ratio  of  the  one  to  the  other 
with  great  accuracy. 

In  examining  the  white  corpuscles  as  to  their  number  we 
sliould  also  notice  any  peculiarity  in  their  size.  This  is 
most  easily  judged  of  by  comparison  with  the  red  corpuscles. 
In  certain  cases  of  leukfemia  the  white  globules  are  of  the 
usual  size,  but  at  other  times  they  are  smaller  than  natural, 
and  a  mixture  of  large  and  small  white  corpuscles  may  some- 
times be  seen.  (See  illustrations  in  Bennett's  work  on 
Leucocytha3mia.)  No  definite  significance  can  as  yet  be 
safely  attached  to  these  variations  in  size,  but  the  facts  ouglit 
to  be  recorded  M'hen  ascertained. 

The  red  corpuscles  may  be  estimated  as  to  their  absolute 
number  in  a  definite  volume  (say  1  cubic  millimeter) :  a 
diminution  in  this  respect  has  been  found  in  cases  of  ana3mia, 
and  variations  may  also  be  noticed  during  the  course  of  the 
treatment.  Changes  in  the  appearance  of  the  red  corpuscles 
are  also  to  be  observed ;  and  any  peculiarity  or  any  deviation 
from  the  usual  apj^earances  ought  to  be  noted,  although  such 
changes  are  generally  due  to  evaporation  and  other  physical 
causes  (crenated  margins,  absence  of  the  running  together 
into  rouleaux,  &c.).  More  serious  changes  in  the  shape  of 
the  red  corpuscles  are  sometimes  seen,  and  have  been  figured, 
but  these  alterations  probably  arise  from  mechanical  pressure 
in  preparing  the  specimen.  Increase  in  the  size  of  the  red 
corpuscles  has  also  been  observed  in  cases  of  anaemia. 

'  For  details  and  illustrations  of  the  instruments  see  Schiifer's 
Practical  Histology,  p.  263  and  261.  See  also  Rutherford's  Practical 
Histology.  The  instruments  are  obtainable  from  M.  Verick,  2  Rue 
de  la  Parcheminerie,  Paris.  Potain's  tube  for  diluting  and  mixing 
the  blood  and  the  Malassez  slide  cost  together  40  francs.  Eye  piece 
micrometers,  with  the  squares  ruled  on  the  glass,  may  be  obtained 
from  the  same  instrument  maker  and  others.  A  modification  of 
Hayem  and  Nachet's  method,  with  a  slide  prepared  as  above  de- 
scribed, and  also  furnished  with  divisions  ruled  on  it,  after  the 
manner  of  a  stage  micrometer,  has  been  devised  by  Dr.  Gowers,  and 
may  be  obtained  from  Hawksley,  instrument  maker  in  London. 
(See  Pract'Uioner,  July,  1878.) 


LIVING  ORGANISMS  IN  BLOOD.         285 

Minute  fragments  of  protoplasm  are  sometimes  seen  in 
specimens  of  blood:  they  appear  as  a  somewhat  granular- 
looking  debris  :  they  may  result  from  rupture  of  the  cor- 
puscles while  applying  the  cover  glass  ;  minute  masses  of  this 
kind  are  sometimes  found  apart  from  this  in  fevers  and 
various  other  diseases,  but  their  significance  is  not  great,  or 
at  least  is  not  yet  properly  known. 

Small  colored  cells,  smaller  than  the  red  corpuscles,  deeper 
in  color,  globular  in  shape  and  differing  in  their  behavior 
with  reagents  have  been  observed  in  certain  cases  of  Per- 
nicious ancemia,  and  are  figured  by  Eichorst  in  his  work  on 
this  subject. 

Another  branch  of  the  microscopic  investigation  of  the 
blood  has  recently  opened  up  a  most  interesting  and  import- 
ant department  of  pathology.  The  existence  of  living  or- 
ganisms in  the  blood  has  now  been  established  in  several 
diseases.  The  earliest  discovered  and  perhaps  the  most 
important  organism  of  this  class  is  that  found  in  the  disease 
known  under  the  names  of  malignant  pustule,  splenic  fever, 
anthrax,  charbon,  and  other  synonyms :  the  organism  is 
found  both  in  the  human  subject  and  in  animals  thus  atfected. 
This  organism  is  a  short,  straight,  motionless  rod,  about  us 
long  as  the  breadth  of  a  blood  corpuscle ;  it  is  named  the 
Bacillus  anthracis,  and  has  been  shown  by  experiment  to 
be  definitely  related  to  the  activity  of  the  virus.  (This  bac- 
terium resembles  a  very  common  and  harmless  one  found  in 
infusions  of  hay,  &c.,  named  the  Bacillus  subtilis,  but  this 
latter  is  endowed  with  motion.) 

In  relapsing  fever  organisms  of  another  class  are  found  in 
the  blood  during  the  paroxysm  of  the  fever,  and  also  in  the 
relapse,  but  not  in  the  apyretic  interval.  They  consist  of 
minute  spiral  fibrils  of  the  most  extreme  tenuity,  and  the 
length  is  from  two  to  six  times  the  breadth  of  a  blood  cor- 
puscle. They  are  named  Sjnrilla  (or  by  Cohn,  Spirocheete 
Ohermeieri)  :  the  spirals  assume  various  forms  in  their  com- 
binations. 

The  Filaria  sanguinis  hominis  (Lewis)  may  also  be  men- 
tioned :  it  is  found  in  the  blood  (and  the  urine)  of  persons 
affected  with  a  certain  form  of  chyluria,  but  as  yet  only  in 
India  and  Australia.  It  is  about  the  breadth  of  a  blood  cor- 
puscle, and  about  7^5*^^  '^^  ^^  i"^'"^  ^"  length,  and  exhibits 
active  wriggling  movements. 

Another  method  of  investigating  the  blood  consists  in  de- 
termining its  richness  in   haemoglobin,  from  the   depth  of 


286  EXAMINATION    OF    THE    BLOOD. 

color  presented  by  a  dilution  of  known  strength.  For  this 
purpose  Potain's  capillary  pipette  for  mixing  the  blood  is 
required,  and  the  whole  instrument  may  be  procured  from' 
the  maker  who  supplies  Malassez's  slide  (see  p.  284).  The 
instrument  is  furnished  with  a  scale  for  comparing  the  depth 
of  color  obtained  with  a  definite  standard,  and  a  table  sup- 
plies the  estimate  of  the  richness  in  htemoglobin.  By  this 
means  we  are  able  to  judge  of  the  impoverishment  of  the 
blood  in  anfemia,  and  to  trace  the  gradual  improvement  oc- 
curring, in  favorable  cases,  under  treatment. 


281 


CHAPTER  X. 

EXAMINATION  OF  THE  FAUCES,  LARYNX,  AND 
NARES. 

THE  FAUCES. 

In  order  to  investigate  the  fauces  and  the  parts  in  that 
neighborhood,  it  is  necessary  to  bring  the  patient  opposite  a 
"window  or  a  lamp  so  arranged  that  the  light  will  pass  through 
the  mouth  to  its  posterior  parts.  If  the  patient  be  now  made 
to  open  his  mouth,  it  will  sometimes  happen  that  the  fauces 
are  at  once  visible.  More  frequently,  however,  the  tongue 
interferes  with  the  view ;  in  its  posterior  parts,  especially,  it 
often  mounts  up,  and,  lying  in  contact  with  the  soft  palate, 
completely  fills  up  the  back  part  of  the  mouth.  It  is  some- 
times a  little  difficult  to  dispose  of  the  tongue,  but  by  varying 
the  procedure  according  to  circumstances  the  difficulties  may 
generally  be  overcome.  It  is  sometimes  sufficient  to  close 
the  nostrils  of  tlie  patient  so  as  to  cause  him  to  breathe  through 
the  mouth,  for  then  the  dorsum  of  the  tongue  must  leave  the 
palate  in  order  to  allow  of  the  passage  of  air.  Very  often  it 
is  necessary  to  press  doAvn  the  tongue,  and  this  may  some- 
times be  done  with  the  finger  of  the  observer,  but  as  a  rule 
it  is  best  performed  with  a  spatula  or  the  handle  of  a  spoon. 
The  best  form  of  tongue  depressor  is  a  flat  metal  plate  slightly 
curved,  so  as  to  give  a  hollow  surface,  fitted  to  adapt  itself  to 
the  dorsum  of  the  tongue.  It  is  an  advantage  that  the  plate 
should  have  an  oval  aperture  near  its  extremity,  because  the 
surface  of  the  tongue  will  project  through  this,  and  by  catch- 
ing on  the  edges  of  the  aperture  prevent  the  instrument  slip- 
ping. If  the  handle  of  a  spoon  be  used,  it  ought  to  be  a 
tablespoon,  and  one  without  any  carving  on  it,  as  this  only 
irritates  the  tongue,  besides  occupying  space.  The  spatula, 
in  whatever  form  it  may  be,  sliould  be  pushed  well  back 
before  being  brought  to  bear  on  the  tongue,  and  should  then 
be  pressed  firmly  downwards  and  forwards.  The  pressure 
should  be  steady  and  firm,  and  if  the  student  practises  on 
himself,  he  will  have  less  difficulty  when  he  comes  to  examine 
a  patient. 


283  FAUCES,    LARYNX,    AND    NARES. 

When  the  tongue  is  thoroughly  depressed  a  full  view  is 
obtained  of  the  uvula  hanging  down  and  tremulous  in  the 
middle  line  ;  the  soft  palate  arching  to  either  side  of  the 
uvula,  and  dividing  into  two  pillars,  which  appear  as  slight 
pi'ojections,  one  in  front  of  the  other ;  tlie  tonsils,  which  in 
the  normal  state  are  hardly  visible  between  the  pillars  of  the 
fauces  ;  and  lastly,  the  pharynx,  Avhose  posterior  wall  is  seen 
behind  the  uvula  and  soft  palate.  It  is  often  possible  by 
moving  the  spatula  from  one  side  of  the  tongue  to  the  other 
to  expose  the  pillars  of  the  fauces  and  the  tonsils  more  fully 
than  by  keeping  it  in  the  middle  line. 

In  order  to  appreciate  the  clianges  which  occur  in  the 
fauces,  it  will  be  necessary  to  familiarize  one's  self  witli  the 
normal  appearances.  But  this  being  premised,  the  principal 
points  to  be  observed  are  these :  The  state  of  the  uvula, 
whether  it  be  unusually  thick,  and  (what  generally  goes 
along  with  this),  unduly  motionless  ;  whether  it  be  altered 
in  color,  in  the  way  of  bright"  red  or  dark  red,  the  former 
usually  indicating  a  more  acute  and  the  latter  a  more  chronic 
inflammation.  Is  there  any  exudation  or  ulceration  on  the 
uvula?  Then  as  to  the  fauces  proper,  is  the  mucous  mem- 
brane covering  these  parts  thickened  or  reddened  or  ulcer- 
ated, or  the  seat  of  an  exudation  ?  Is  there  any  enlargement 
or  other  change  visible  in  the  tonsils  or  their  neighborhood  ? 
A  systematic  examination  of  each  part  with  a  direct  view  to 
determining  the  facts  in  regard  to  these  various  conditions 
will  be  of  great  consequence. 

Morbid  Appearances  in  the  Fauces. — But  now  it 
v^'ill  be  well  to  give  some  indication  of  the  conditions  actually 
met  with  in  certain  of  the  commoner  diseases.  The  com- 
monest of  all  is  Catarrh,  in  which,  as  a  general  rule,  fauces, 
pharynx,  and  tonsils  all  take  some  part.  If  the  disease  be 
acute  Ave  will  find  the  whole  soft  palate  of  a  red  color,  and 
there  is  considerable  swelling,  especially  of  the  uvula.  The 
uvula  is  both  longer  and  thicker  than  usual,  the  reason  being, 
that  as  its  tissue  is  looser  and  freer  on  all  sides,  the  inflam- 
matory exudation  has  more  room  to  accumulate  here,  and 
the  uvula  may  become  quite  plump  and  bulky.  The  pharynx 
is  also  seen  to  be  red,  and  in  certain  stages  of  the  disease  it 
may  be  found  covered  with  a  mucous  or  muco-purulent  secre- 
tion. The  tonsils  are  for  the  most  part  swollen,  and  they 
project  towards  the  middle  line.  In  the  chronic  form  of  the 
disease  the  mucous  membrane  is  of  a  duller  red,  and  the 
swelling  is  less  uniform.     The  uvula  is  elongated,  thickened, 


MORBID    APPEARANCES    IN    THE    FAUCES.         289 

and  unduly  rigid,  but  it  has  not  the  plump,  bulky  appearance 
of  the  acute  disease,  and  some  dilated  veins  may  be  visible 
on  it.  The  mucous  membrane  of  the  pharynx  is  seen  to  be 
rough  on  the  surface,  from  the  thickening  being  irregular, 
and  little  projections  occur  at  short  intervals.  There  may 
be  small  superficial  ulcers  visible  in  this  disease  on  the  soft 
palate,  tonsils,  or  pharynx. 

In  Scarlet  fever  the  condition  of  the  fauces  is  that  of  an 
acute  inflammation,  and  the  conditions  presented  are  very 
like  those  just  referred  to.  The  uvula,  palate,  tonsils,  and 
pharynx  are  generally,  even  in  the  mildest  cases,  red  and 
swollen.  The  red  and  swollen  mucous  membrane  is  often 
covered  with  a  layer  of  tenacious  mucus,  and  in  the  more 
severe  cases  the  tonsils  may  be  so  much  swollen  as  almost  to 
obstruct  the  fauces.  All  these  processes  are  acute,  developed 
in  the  course  of  a  comparatively  few  hours.  In  the  more 
severe  cases  there  is  more  than  a  simple  catarrhal  inflamma- 
tion. Instead  of  a  layer  of  mucus  on  the  mucous  membrane, 
there  appear  specks  and  patches  of  a  gray  color,  which  seem 
to  be  adhering  to  the  surface,  altliough  they  can  generally 
be  removed  without  breach  of  surface.  Along  with  this 
catarrh,  as  in  simple  catarrhal  inflammation,  superficial 
ulcers  may  form,  which  are  not  to  be  mistaken  for  the 
patches  about  to  be  mentioned.  But  sometimes  there  is 
actual  sloughing  of  parts  of  the  mucous  membrane,  and  the 
sloughs  coming  away  leave  deeper  irregular  ulcers.  This 
sloughing  is,  however,  only  met  with  in  very  exceptionally 
severe  cases,  and  scarcely  in  the  earlier  periods.  It  is  to  be 
remembered  that  the  condition  seen  in  the  throat  may  extend 
to  parts  which  are  invisible,  especially  to  the  posterior  nares. 
Important  elements  in  the  diagnosis  of  the  scarlet  fever  throat 
will  be  supplied,  of  course,  by  the  state  of  the  tongue,  the 
rash  on  the  skin,  and  the  other  indications  of  the  specific 
fever. 

In  Diphtheria  we  have  also  an  acute  inflammation  of  the 
same  parts,  but  the  appearances  presented  are  very  different. 
The  mucous  membrane  here  is  red  and  swollen,  but  the  at- 
tention is  very  particularly  called  to  the  existence  of  a  pecu- 
liar exudation  on  the  surface.  Instead  of  the  tenacious 
mucus,  there  appear  on,  or  one  might  almost  say,  in  the 
mucous  membrane  of  the  fauces,  specks  and  patches  of  a 
white  color.  These  are  mostly  met  with  on  the  uvula  and 
palate,  but  they  are  often  seen  on  the  surface  of  the  tonsils 
and  pharynx,  and  even  in  various  parts  of  the  mouth.  The 
25 


290  FAUCES,    LARYNX,    AND    NARES. 

patches  are  at  first  white,  but  they  soon  get  darker  in  color 
from  dirt  and  blood.  This  white  material  really  involves 
the  mucous  membrane  as  well  as  appearing  on  its  surface, 
and  the  consequence  is  sloughing  of  the  superficial  layers  of 
mucous  membrane.  The  sloughs  and  exudations  separate 
and  fall  off,  hanging  from  the  surface  as  shreddy,  ragged 
masses.  It  should  be  remembered  that  the  inflammation 
does  not  usually  confine  itself  to  the  parts  seen,  but  often 
extends  down  into  tlie  pharynx  and  larynx,  and  upwards 
into  the  posterior  nares. 

It  is  very  important  to  be  able  to  distinguish  the  exuda- 
tion which  is  so  characteristic  of  diphtheria  from  conditions 
of  a  different  nature,  and  to  judge  from  the  frequency  with 
which  simple  diseases  of  the  throat  are  called  diphtheria,  the 
distinction  does  not  seem  to  be  very  easy.  All  kinds  of 
ulcers  maybe  mistaken  for  diphtheritic  patches,  especially  as 
they  may  be  coated  with  a  whitish  secretion.  Ulcers  are 
met  with  in  ordinary  catarrhal  inflammations,  and  these  are 
most  frequently  seated  on  the  soft  palate,  the  tonsils,  or  the 
pharynx.  Ulcers  also  occur  in  scarlet  fever,  and  there  they 
have  similar  seats.  In  smallpox  also  we  may  have  ulcers 
and  other  evidences  of  acute  inflammation  in  these  regions, 
but  the  eruption  on  the  skin  will  prevent  any  mistake  being 
made.  It  should  be  remembered  that  the  diphtheritic  patch 
is  an  exudation  on  and  in  the  mucous  membrane,  and  is 
therefore  raised  above  the  surface,  whereas  an  ulcer,  of 
whatever  kind,  is  depressed  below  it.  There  is  a  form  of 
disease  which  resembles  the  exudation  of  diphtheria  more 
closely  than  any  other,  but  which  can  hardly  be  mistaken 
for  it,  and  that  is  the  condition  found  in  the  mouth  and 
known  as  Thrush  or  Muguet.  These  patches  often  extend 
to  the  fauces,  pharynx,  and  even  further,  and  as  the  peculiar 
white  appearance  is  due  to  an  excess  of  epithelium  united 
into  a  membrane  by  the  threads  of  a  fungus,  the  patch  may 
have  a  superficial  resemblance  to  that  of  diphtheria.  But 
the  existence  of  these  patches  on  different  parts  of  the 
mouth,  and  their  characters  on  close  inspection,  as  well  as 
the  general  symptoms,  ought  to  prevent  any  such  mistake. 
The  microscopic  examination  may  also  assist  us,  by  reveal- 
ing the  presence  of  a  vegetable  parasitic  growth.  (See  Fig. 
30,  p.  305.) 

Phlegmonous  Inflammation  of  the  Fauces.  Tonsillitis. — 
If  this  inflammation  be  acute,  which  it  generally  is  at  the 
first,  one  or  both  tonsils  will  be  found  much  enlarged,  pro- 


TONSILLITIS — SYPHILIS.  291 

jecting  towards  the  middle  line ;  their  surface  is  coarsely 
nodulated,  and  often  covered  with  a  tenacious  exudation. 
The  mucous  membrane  of  the  entire  fauces,  and  frequently 
also  of  the  pharynx,  has  a  dark  red  color.  The  enlarged 
tonsils  can  generally  be  felt  by  external  examination,  and 
the  patients  have  usually  a  peculiar  voice,  as  if  they  were 
speaking  with  something  stuck  in  their  throat.  The  intlam- 
niation  often  goes  on  to  suppuration,  and  then  abscesses 
form  in  the  tonsils,  and  these  may  be  seen  before  they  have 
burst  as  smooth  rounded  projections  from  the  general 
contour. 

After  these  abscesses  have  burst  the  tonsils  will  be  found 
still  a  good  deal  larger  than  normal,  and  they  will  present  an 
irregular  ragged  appearance  at  the  place  where  the  suppura- 
tion has  occurred.  Sometimes  suppuration  takes  place  in 
other  parts  besides  the  tonsils,  even  when  the  acute  inflam- 
mation has  begun  in  the  tonsils,  and  in  these  cases  we  may 
have  abscesses  forming  in  the  soft  palate  or  in  the  pillars  of 
the  fauces ;  but  suppuration  there  is  much  less  common  than 
in  the  tonsils  themselves.  As  these  inflammations  of  the 
tonsils,  whether  they  go  on  to  suppuration  or  not,  are  very 
liable  to  recur,  and  often  assume  a  more  chronic  form,  sub- 
ject to  acute  exacerbations,  we  often  meet  with  patients  with 
permanently  enlarged  tonsils.  Such  tonsils  are  hard  and 
uneven  on  the  surface,  having  often  an  appearance  as  if 
ploughed  up  by  cicatrices. 

Syphilis — We  have  still  to  describe  the  appearances  in 
syphilitic  disease  of  the  fauces.  Syphilis  may  manifest  itself 
here  as  a  simple  inflammation,  presenting  great  resemblance 
to  the  catarrhal  inflammation  already  described.  The  catarrh 
is  more  persistent,  but  apart  from  the  history  nothing  may 
indicate  its  specific  origin.  In  other  cases,  however,  the 
disease  is  followed  by  extensive  ulceration.  Before  the  ul- 
ceration begins  there  is  swelling  of  the  mucous  membrane, 
and  there  may  even  be  more  defined  tumors  visible  (gummy 
nodules).  The  ulcers  which  form  are  usually  situated  on  the 
soft  palate  or  uvula,  but  may  attack  the  pharynx.  They 
generally  cause  considerable  destruction  of  the  mucous  mem- 
brane, and  in  this  way  it  is  not  uncommon  to  meet  with 
cases  in  which  the  soft  palate  and  the  uvula  are  eaten  away 
in  great  part.  The  loss  of  the  soft  palate  will  cause  the  per- 
son to  have  a  peculiar  nasal  voice,  and  his  pronunciation  of 
certain  letters  will  be  imperfect,  because  he  is  unable  to  close 
the  nares  during  phonation.     Almost  the  only  disease  likely 


292  FAUCES,   LARYNX,    AND    NARES. 

to  be  confused  with  this  is  cancerous  disease  with  ulceration. 
If  it  be  remembered  that  in  sypliilis  there  is  always  some 
other  indication  of  specific  disease,  it  is  hardly  possible  to 
make  a  serious  mistake. 

Retro-Pharyngeal  Abscess — It  is  necessary  to  bear  in 
mind  that  abscesses  occasionally  form  behind  the  pharynx, 
between  it  and  bodies  of  the  vertebrte,  retro-  or  post-pharyn- 
geal  abscesses.  The  abscess  presses  forward  the  mucous 
membrane  of  the  pharynx,  which  may  be  seen  bulging  for- 
ward, or  felt  as  an  elastic  tumor  behind  the  soft  palate,  and 
sometimes  it  forms  a  serious  obstruction  to  respiration  and 
deglutition.  The  abscess  generally  originates  in  disease  of 
the  vertebrae,  but  may  have  other  causes,  especially  in  child- 
ren. Abscesses  originating  in  the  vertebrai  sometimes  point 
externally  in  the  neck. 

The  elucidation  of  many  of  the  matters  above  referred  to 
may  often  be  facilitated  by  the  use  of  the  finger.  The  state 
of  the  tonsils,  for  instance,  or  the  consistence  of  any  swelling 
can  be  thus  explored  ;  while,  at  the  same  time,  information 
is  gained  as  to  the  state  of  sensitiveness  of  the  part.  It  is 
often  useful  to  assist  the  internal  exploration  by  using  the 
other  hand  outside,  so  as  to  place  the  tissues  between  the 
finger  inside  and  that  outside. 

THE  LARYNX. 

Laetxgoscope. — The  examination  of  the  larynx  is  not  a  difficult 
process,  but  one  which  requires  a  certain  amount  of  practice,  pa- 
tience, and  tact.  Before  detailing  the  various  steps  in  the  pro- 
cedure, it  may  be  well  to  refer  to  certain  matters  connected  with 
light  and  instruments.  It  is  necessary  to  he  provided  with  a  lamp 
of  some  kind,  and  as  it  is  important  that  the  light  should  be  near 
the  level  of  the  patient's  mouth,  the  lamp  must  be  capable  of  being 
raised  and  lowered.  It  is  also  well,  where  possible,  to  surround 
the  flame  with  an  opaque  tube  open  only  at  one  side,  because  this 
enables  one  to  have  the  room  dark,  and  the  apparent  intensity  of 
the  illumination  is  thereby  increased.  A  convenient  form  of  gas 
lamp  is  that  used  in  the  London  Hospital  for  Diseases  of  the  Throat, 
and  now  adopted  in  many  institutions.  It  consists  of  a  gas  bracket 
in  two  parts.  The  part  next  the  wall  consists  of  two  parallel  tubes, 
so  arranged  that  in  elevating  and  depressing  the  bracket,  the  other 
part,  which  is  jointed  to  this,  remains  horizontal.  In  this  way  the 
flame  is  always  in  the  pei-pendicular  in  position.  The  gas  burner 
is  an  Argand,  and  instead  of  the  ordinary  glass  funnel,  it  is  pro- 
vided with  a  metal  cylinder,  into  one  side  of  which,  at  a  level  cor- 
responding with  the  flame,  is  fitted  a  strong  plano-convex  or  bull's- 
eye  lens.  The  efi'ect  of  this  is  that,  while  no  light  escapes  except 
from  one  side,  the  light  escaping  here  has  its  rays  rendered  nearly 


LARYNGOSCOPE.  293 

parallel,  and  it  can  be  brought  to  bear  much  more  powerfully  on 
any  given  object.  The  student  may  make  use  of  any  lamp  which 
gives  a  bright  light,  and  which  can  be  raised  or  lowered  as 
desired. 

We  require,  in  the  next  place,  some  apparatus  for  concentrating 
the  light  on  the  patient's  fauces.  It  is  not  well,  as  a  rule,  to  do 
this  by  the  direct  light  of  the  lamp  ;  a  concave  mirror  having  a 
rather  long  focus  is  the  most  convenient  arrangement.  In  order 
that  the  hands  may  be  free,  it  is  requisite  to  have  this  mirror  fixed 
to  the  head  in  some  way  or  other.  This  is  done  in  various  ways, 
the  two  commonest  being  a  strap  round  the  head,  and  a  spectacle 
frame.  The  present  writer  has  been  in  the  habit  lately  of  using 
the  latter,  and  finds,  among  other  advantages,  that  the  ease  with 
which  it  can  be  put  off  or  on  renders  it  very  convenient.  Which- 
ever method  of  fixing  be  used,  the  reflector  should  be  worn  over 
one  eye,  in  such  a  position  that  the  eye  which  is  covered  by  it  can 
look  through  the  hole  which  should  always  exist  in  the  centre  of 
the  reflector.  (It  is  not  sufficient  to  have  clear  glass  in  the  centre, 
but  the  reflector  should  be  actually  perforated.)  The  reflector 
should  be  placed  over  the  eye  nearest  to  the  lamp,  and  in  such  a 
position  that  while  this  eye  is  protected  from  the  light  of  the  lamp, 
the  shadow  of  the  reflector,  projecting  a  little  to  the  other  side  of 
the  ridge  of  the  nose,  will  screen  the  other  eye  from  the  glare  of  the 
lamp.  If,  for  instance,  the  lamp  be  placed  to  the  right  of  the  ob- 
server, then  the  reflector  will  be  placed  over  his  right  eye.  The 
right  eye,  while  protected  from  the  lamp,  will  be  able  to  look 
through  the  aperture  at  the  patient,  and  the  left  eye  will  be  shaded 
by  the  edge  of  the  reflector,  but  will  be  free  iu  other  directions. 

The  laryngeal  mirror  is  a  small  mirror  mounted  on  a  stem,  and 
intended  to  be  placed  in  the  fauces  of  the  patient,  so  as  to  catch 
the  light  and  direct  it  down  to  the  larynx,  and  at  the  same  time 
reflect  the  image  of  the  larynx  towards  the  eyes  of  the  observer. 
The  observer  should  be  provided  with  mirrors  of  different  sizes,  and 
he  should  see  that  the  stem  j^asses  off  directly  from  the  border  of 
the  mirror,  there  being  serious  objections  to  the  arrangement  by 
which  the  wire  forming  the  stem  is  carried  a  certain  distance  out 
from  the  mirror  before  being  turned  down  to  form  the  stem. 

We  may  now  turn  to  the  procedure  in  the  actual  examination  of 
the  patient.  In  order  to  a]3preciate  the  difficulties  of  this  process 
and  to  understand  the  mechanism,  it  is  strongly  to  be  recommended, 
that  the  student  will  begin  by  practising  on  himself.  A  short 
paragraph  on  Auto-Laryngoscopy  will  be  added  to  this  description. 
For  an  ordinary  examination  the  patient  and  observer  should  be 
seated  on  two  chairs  facing  each  other.  The  lamp  may  be  conve- 
niently placed  to  the  patient's  left ;  it  ought  to  be  about  the  level 
of  his  ear,  and  as  near  his  head  as  may  be  convenient.  The  ob- 
server, with  the  reflector  over  his  right  eye,  moves  the  reflector  till 
the  bright  liglit  falls  on  the  patient's  face.  He  then  asks  the  pa- 
tient to  open  his  mouth,  and  observes  that  the  head  is  so  placed 
that  the  ra^^s  of  light  can  find  free  access  to  the  fauces.  Frequently 
the  head  is  bent  to  one  side  or  the  other,  and  this  should  be  rectified. 
The  patient  should  also  be  made  to  sit  straight  up  with  the  neck 
somewhat  stretched,  and  the  head  inclined  backwards.    Before  pro- 

25* 


294  FAUCES,    LARYNX,    AND    NARES. 

ceeding  further  all  these  points  should  be  noted  and  a  full  illumina- 
tion of  the  mouth  obtained.  At  this  stage  it  will  often  be  impossible 
to  see  the  fauces,  because  the  tongue  obstructs  the  view,  and  it  is 
necessary  in  the  next  place  to  get  it  disposed  of.  It  is  not  sufficient 
here  to  depress  the  tongue  with  a  spatula,  because  when  the  laryn- 
geal mirror  is  introduced,  the  back  part  of  the  tongue  will  probably 
be  raised,  and  spatula  and  dorsum  pushed  against  the  mirror.  It 
is  most  convenient  to  ask  the  patient  to  put  out  his  tongue,  and  to 
catch  it  with  the  finger  and  thiimb  of  the  left  hand,  a  napkin  being 
used  for  purposes  of  cleanliness,  and  also  to  prevent  the  organ  slip- 
ping from  the  grasi?.  The  tongue  shoiild  simply  be  taken  hold  of, 
it  should  not  be  dragged  forward,  all  that  is  wanted  being  to  pre- 
vent it  slipping  back  and  the  dorsiim  mounting  up  against  the  soft 
palate.  The  tongue  being  thus  secured,  a  full  view  of  the  fauces 
should  be  obtained,  and  it  is  well  to  be  sure  of  this  view  before  pro- 
ceeding further. 

The  next  procedure  is  the  introduction  of  the  laryngeal  mirror. 
It  should  be  slightly  heated  before  being  introduced,  othei'wise  the 
breath  condensing  on  it  dims  the  surface.  It  is  best  heated  by 
placing  it  over  the  lamp,  and  it  should  be  held  with  the  surface  of 
the  mirror  downwards  so  that  the  surface  can  be  seen.  The  vapor 
produced  in  the  combustion  of  the  lamp  at  first  condenses  on  the 
surface-,  but  as  the  temperature  rises  the  vapor  is  cleared  away,  and 
the  mirror  resumes  its  brightness.  When  this  has  occurred  it  is 
ready  for  introduction  ;  but  before  introduction,  the  back  of  it 
shoiild  be  aj)plied  to  the  skin,  say  of  the  left  hand,  to  see  that  it  is 
not  too  hot.  The  patient  will  see  you  apply  it  to  your  own  skin, 
and  will  not  dread  that  he  is  going  to  have  his  throat  burned.  The 
tongue  being  held  in  the  left  hand,  and  the  fauces  continuously 
illuminated,  the  heated  mirror  is  now  to  be  introduced  into  the 
mouth,  and  in  doing  this  the  right  hand  will  be  kept  to  the  right 
of  the  middle  line,  and  slightly  below  the  level  of  the  mouth,  so  as 
not  to  come  between  the  lamp  and  the  eyes  of  the  observer.  The 
mirror  is  passed  backwards,  keeping  its  surface  parallel  with  the 
tongue,  and  taking  care  not  to  touch  any  of  the  structures  in  the 
mouth  with  it.  It  is  so  introduced  that  the  stem  lies  in  the  left 
half  of  the  mouth,  coming  out  near  the  left  angle.  The  mirror  is 
kept  in  the  middle  line,  and  is  pressed  against  the  uvula,  which 
it  pushes  backwards  and  upwards  towards  the  posterior  nares. 
The  instrument  should  be  held  delicately,  but  steadily,  in  the 
hand.  Any  tremuloiisness  has  the  effect  of  tickling  the  fauces, 
and  is  apt  to  bring  on  reflex  efibrts  at  vomiting,  which  necessitate 
the  withdrawal  of  the  mirror.  Just  as  the  mirror  is  being  placed, 
the  patient  should  be  asked  to  say  "ah,"  and  the  instrument 
should  be  pushed  home  while  he  is  doing  this.  The  eff'ect  of  pro- 
nouncing this  vowel  is,  that  the  mouth  is  at  once  fully  opened,  and 
the  uvula  drawn  somewhat  up. 

The  first  object  to  come  into  view  is  the  back  of  the  tongue  with 
its  large  circumvallate  papillje.  Then  the  tip  of  the  epiglottis  will 
be  seen,  and  it  is  j^robable  that  for  some  time  the  beginner  will  see 
little  more.  By  carefully  adjusting  the.  mirror,  however,  and  by 
asking  the  patient  to  say  "  ah,"  the  movements  of  the  laryngeal 
structures  will  by  and  by  attract  the  eye  and  suggest  such  changes 


LARYNGOSCOPY    AND    AUTO-LARYNGOSCOPY.      295 

in  tlie  position  of  the  observer  and  of  the  mirror  as  to  bring  the 
interior  of  the  larynx  itself  into  view.  As  a  general  rule,  the  mo- 
bile arytenoid  and  associated  cartilages  will  come  first  into  view 
immediately  behind  the  epiglottis.  By  inclining  the  mirror  more 
downwards,  the  vocal  cords  may  be  exposed  as  two  pearly-white 
bands  extending  from  the  arytenoids  forward  as  if  into  the  base  of 
the  epiglottis.  The  great  difficulty  in  the  way  of  obtaining  a  full 
view  of  the  vocal  cords  is  the  epiglottis,  which  often  hangs  down 
so  that  only  the  arytenoid  cartilages,  and  sometimes  not  even  they, 
can  be  seen  behind  it.  Something  may  be  done  to  raise  the  epi- 
glottis by  havii]g  the  tongue  well  protriided,  the  glosso-epiglotti- 
dean  ligaments  pulling  the  epiglottis  upwards.  A  great  deal  may 
also  be  done  by  asking  the  patient  to  say  "a"  (as  in  hate),  for  the 
pronunciation  of  this  vowel  causes  the  base  of  the  tongue  to  be 
brought  forward.  It  is  impossible  to  say  "a"  with  the  mouth 
open,  but  an  approach  to  it  will  be  made,  and  in  the  effort  the 
epiglottis  will  be  raised.  It  is  generally  possible  by  this  means  to 
get  a  view  of  the  cords  even  to  tlieir  anterior  extremities.  But 
sometimes  even  this  fails,  and  it  is  necessary  to  use  a  further 
method.  .  The  epiglottis  is  most  fully  raised  in  enunciating  the 
vowel  "e"  (as  in  me),  but  with  the  mouth  opeii  and  the  tongue 
held  out  it  is  impossible  even  to  attempt  to  say  "e."  If  the  pa- 
tient be  asked,  however,  to  say  ''ah'"  "  e"  (as  in  saying  aye  slowly 
and  prolonging  the  e),  the  mere  attempt  to  pass  from  the  one  vowel 
to  the  other  will  result  in  a  pulling  up  of  the  epiglottis.  This  will 
generally  be  successful  in  the  worst  cases,  but  it  is,  of  course,  only 
a  glimpse  that  one  gets  while  the  actual  phonation  is  in  progress. 

Next  to  the  difficulty  with  the  epiglottis,  the  most  serious  obsta- 
cle to  laiyngeal  examination  is  the  tendency  to  retch  which  many 
patients  present  when  the  mirror  is  placed  in  the  fauces.  There 
are  very  great  individual  differences  in  this  respect,  and  the  diffi- 
culty can  only  be  overcome  by  patience.  It  is  sometimes  neces- 
sary to  ask  the  patient  to  tickle  his  fauces  frequently  with  a  feather, 
in  order  to  accustom  them  to  the  contact,  and  after  a  few  days  they 
generally  get  sufficiently  non-sensitive.  When  the  straining  efforts 
set  in,  it  is  necessary  to  withdraw  the  mirror,  as  the  pharynx  con- 
tracts and  completely  closes  the  view;  and,  besides  this,  whenever 
retching  has  occurred,  it  is  generally  impossible  to  get  a  good  view 
at  that  sitting.  If  the  fauces  are  very  exceptionally  sensitive,  the 
best  plan  is  to  cause  the  patient  to  suck  ice  for  about  ten  minutes 
before  the  examination. 

Atjto-Laryngoscopy  may  be  practised  in  various  ways.  A  very 
simple  plan  is  that  of  Dr.  Foiilis,  in  which  a  globe  filled  with  water 
is  used  to  condense  the  light,  and  a  little  piece  of  looking-glass  is 
placed  above  this  condenser  to  enable  the  image  to  be  seen.  The  globe 
may  be  had  in  a  glassblower's,  and  is  of  the  kind  used  by  jewellers 
to  concentrate  light  on  their  work.  It  is  mounted  in  a  simple  way 
on  a  candle-stick,  and  placed  in  front  of  the  light.  The  observer 
sits  in  front  of  it,  allows  the  light  to  fall  on  his  fauces,  introduces 
the  mirror  after  heating  it,  and  observes  the  image  in  the  piece  of 
looking-glass  above  the  condenser.  Another  simple  method  is  for 
the  observer  to  seat  himself  with  the  lamp  in  the  same  relation  to 
him  as  it  would  be  to  a  jjatient.     Then  in  front  of  him  are  fixed 


296        FAUCES,  LARYNX,  AND  NARES. 

the  ordinary  laryngeal  reflector  lield  in  some  kind  of  stem,  and 
side  by  side  with  it  a  small  toilet-mirror  or  hand-glass.  The  light 
coming  from  the  lamp  is  reflected  on  the  fauces  just  as  in  the  case 
of  a  patient,  and  the  image  is  seen  in  the  mirror  or  hand-glass.  A 
very  ingenious  method  is  that  of  Dr.  George  Johnson,  and  perhaps 
it  is  the  best,  as  it  needs  no  special  apparatus.  The  observer  sits 
down  in  front  of  an  ordinary  looking-glass,  which  has  a  lamp 
placed  at  one  side.  He  puts  on  the  oi-dinary  reflector,  and  so 
manipulates  it  that  he  illuminates  his  fauces,  as  seen  in  the  looking- 
glass,  as  if  it  were  the  fauces  of  a  patient,  and  when  this  has  been 
done,  introduces  the  laryngeal  mirror  into  his  own  fauces  as  before. 
The  objection  to  tliis  method  is  that  the  image  being  twice  reflected 
is  not  very  clear,  but  it  approaches  mucli  more  closely  to  the  ex- 
amination of  a  patient  than  either  of  the  others.  If  the  looking- 
glass  be  a  thoroughly  good  one,  and  its  surface  well  cleaned,  this 
method  presents  little  diliiculty. 

It  is  impossible  here  fully  to  describe  the  appearances  pre- 
sented by  the  normal  larynx,  these  should  be  made  familiar 
by  practice ;  but  we  must  refer  to  the  principal  points  which 
ought  to  be  taken  particular  notice  of.  The  laryngeal  mir- 
ror reveals  the  mucous  membrane  over  the  small  cartilages 
at  the  back  of  the  larynx,  the  arytenoids,  and  the  cartilages 
of  Santorini  and  Wrisberg,  The  general  contour  of  these 
cartilages  as  well  as  the  appearance  of  the  mucous  membrane 
should  be  noticed.  Then  the  aryteno-epiglottidean  folds 
which  form  the  lateral  borders  of  the  upper  opening  of  the 
larynx,  can  be  seen  passing  obliquely  backwards  from  the 
epiglottis.  At  the  bottom  of  the  larynx  the  true  cords  at- 
tract attention,  appearing  as  flat  pearly-white  bands  which 
are  very  mobile,  and  during  vocalization  come  close  together. 
Above  the  vocal  cords  and  parallel  with  them,  but  separated 
by  a  space,  are  the  ventricular  bands  which  are  often  called 
the  "false  cords."  They  are  folds  of  mucous  membrane 
running  in  a  direction  from  before  backwards.  Between 
each  band  and  the  corresponding  vocal  cord  we  can  generally 
see  a  slit,  this  is  the  opening  of  the  ventricle  of  the  larynx 
which  forms  a  shallow  pouch,  nothing  of  which  is  seen  ex- 
cept the  slit-like  opening. 

Tlie  introduction  of  the  finger  may  sometimes  supply  us 
with  a  good  deal  of  information  as  to  the  state  of  the  larynx, 
where  laryngoscopy  is  difftcult,  inconvenient,  or  not  availa- 
ble. The  index  finger  should  be  introduced  at  the  angle  of 
the  patient's  mouth,  the  other  fingers  being  semi-flexed,  and 
the  hand  lying  against  the  patient's  cheek  and  lower  jaw. 
The  fork  between  the  index  and  middle  fingers  will  soon 
come  against  the  angle  of  the  mouth,  but  by  pushing  the 


MORBID    APPEARANCES    IN    LARYNX.  297 

hjiTid  along  the  cheek  the  angle  of  the  mouth  can  often  be 
considerably  stretched  backwards  towards  the  angle  of  the 
lower  jaw.  By  directing  the  index  finger  along  the  edge, 
and  past  the  dorsum  of  the  tongue,  the  upper  edge  of  the 
epiglottis  and  the  neighboring  parts  can  be  distinctly  felt. 
Any  roughness  or  thickening  of  the  epiglottis  can  thus  be 
distinguished,  and  also  any  swelling  of  the  aryteno-epiglotti- 
dean  folds.  Ulceration  or  tumor  of  the  larynx  may  likewise 
be  recognized  in  this  way. 

Morbid  Appearances  in  the  Larynx The  student, 

having  made  himself  familiar  with  the  normal  appearances 
of  the  larynx,  will  be  prepared  to  attempt  the  investigation 
of  morbid  states.  A  laryngoscopic  investigation  will  be  un- 
dertaken whenever  anything  directs  special  attention  to  the 
throat.  If  there  is  any  change  in  the  voice,  any  hoarseness, 
or  even  a  slight  variation  from  the  usual  tone  as  appreciated 
by  the  patient's  friends  ;  if  there  is  any  pain  either  sponta- 
neous or  occasioned  by  speaking,  swallowing  or  on  handling 
the  larynx  ;  if  there  is  a  cough  which  is  not  accounted  for 
by  the  state  of  the  lungs,  and  which  may  have  its  origin  in 
the  larynx  ;  in  all  these  cases  an  examination  of  the  larynx 
will  be  called  for  and  should  be  undertaken.  It  will  not  be 
possible  to  do  more  than  indicate  very  briefly  the  appear- 
ances presented  in  certain  of  the  more  common  diseases  of 
the  larynx. 

In  acute  Catarrh  there  maybe  considerable  thickening  of 
the  mucous  membrane,  and  this  thickening  will  in  great 
part  be  due  to  inflammatory  oedema.  It  is  not  usual,  how- 
ever, to  have  extreme  thickening  in  simple  catarrh,  although 
the  possibility  of  it  must  not  be  lost  sight  of.  The  mucous 
membrane  will  be  red,  and  the  redness  will  be  somewhat 
bright.  In  chronic  catarrh  there  is  a  more  permanent 
thickening  of  the  mucous  membrane,  and  its  color  is  deeper 
than  that  of  the  normal  larynx.  The  thickening  may  be  no 
more  than  to  obscure  the  outlines  of  the  cartilages  in  the 
posterior  parts  of  the  larynx,  and  to  make  the  ventricular 
bands  more  prominent.  But  it  may  assume  very  great  pro- 
portions, and  in  some  cases  the  mucous  membrane  and  sub- 
mucous tissue  develop  such  a  quantity  of  dense  connective 
tissue  that  the  larynx  is  greatly  contracted  and  the  struc- 
tures deformed  and  rendered  rigid.  Sometimes  the  thicken- 
ing so  affects  the  aryteno-epiglottidean  folds  that  they  stand 
out  as  rounded  prominences  and  form  very  conspicuous 
objects.     In  severe  cases  ulcers  generally  form,  but  these  are 


298  FAUCES,    LARYNX,    AND    NARES. 

mostly  superficial  and  are  not  neai-ly  so  prone  to  attack  the 
vocal  cords  as  in  other  forms  of  ulceration.  Of  course  in 
acute  catarrh  there  will  be  profuse  expectoration,  while  in 
the  chronic  form  there  will  be  an  expectoration  of  small 
quantities  of  tough  mucus.  It  should  be  added  that  catarrh 
of  the  larynx,  whether  acute  or  chronic,  is  very  often  associ- 
ated with  catarrh  of  the  fauces  and  pharynx,  for  the  appear- 
ances in  which  see  p.  288. 

In  Phthisis  of  tlie  larynx,  there  is  a  chronic  catarrh,  but 
it  is  not  accompanied  with  great  thickening,  and  the  most 
marked  appearances  are  those  due  to  ulceration.  The  ulcer- 
ation may  be  confined  to  one  side,  or  at  least  it  is  generally 
more  pronounced  on  one  side  than  the  other.  It  usually 
begins  in  the  posterior  parts,  very  often  just  at  the  posterior 
extremities  of  the  cords,  and  it  attacks  the  vocal  cords  pretty 
early.  When  small  the  ulcers  are  not  very  marked,  and  are 
most  readily  recognized  by  the  ragged  edges  which  they 
commonly  present.  There  may  be  very  extensive  superfi- 
cial ulceration,  even  extending  up  the  epiglottis,  and  some- 
times the  ulceration  induces  deep  disease  of  the  cartilages. 
In  these  cases  there  is  hoarseness  or  loss  of  voice,  and  as  the 
ulceration  generally  attacks  the  cords  early,  the  change  in 
the  voice  is  usually  an  early  symptom. 

In  Syphilis  we  may  have  a  catarrh  of  the  larynx  not  dis- 
tinguishable in  its  appearances  from  ordinary  catarrhs. 
Occasionally  condylomata  or  mucous  patches  occur,  and  may 
be  seen  as  definite  tumors  on  the  cords  or  elsewhere,  or  as 
flat  prominences.  Syphilitic  ulceration  is  not  very  common, 
but  sometimes  it  is  very  extensive.  No  other  form  of  dis- 
ease produces  such  extensive  destruction  of  tissue,  and  this 
destruction  may  involve  neighboring  structures. 

Inflammation  of  the  cartilages  of  the  larynx  or  rather  ot 
their  perichondrium  may  be  at  the  basis  of  a  chronic  laryn- 
geal catarrh,  or  even  of  an  acute  catarrh.  In  this  disease, 
however,  there  is  much  greater  pain,  especially  on  handling 
the  larynx. 

In  Croup  and  Diphtheria  we  are  seldom  called  on  to  ex- 
amine the  larynx,  as  the  disease  is  sufficiently  obvious  on 
other  grounds  ;  but  if  we  are,  the  white  exudation  coating  the 
mucous  membrane  will  be  visible.  Here  the  exudation  is 
not  involved  in  the  mucous  membrane,  as  it  is  in  the  mouth 
and  fauces,  but  lies  on  its  surface,  and  comes  away  without 
ulceration. 

(Edema  glottidis  must  also  be   referred  to  in   this  place. 


PARALYSIS    AND    SPASM    OF    VOCAL    CORDS.      299 

This  is  a  condition  which  may  supervene  on  any  acute  in- 
flammation of  the  larynx.  It  is  met  Tvith,  but  not  commonly, 
in  acute  catarrh.  It  occurs  in  the  laryngitis  induced  by  the 
pustular  eruption  of  smallpox  which  very  often  spreads  to 
the  larynx.  It  may  be  the  consequence  of  syphilitic  or  tu- 
bercular disease,  and  sometimes  supervenes  on  inflammation 
of  the  cartilages,  or  it  may  be  a  concomitant  of  erysipelas. 
The  fluid  accumulates  in  the  submucous  tissue  of  the  larynx, 
the  oedema  being  generally  the  consequence  of  an  acute  in- 
flammation of  the  mucous  membrane.  Just  as  in  oedema  of 
the  skin  the  fluid  accumulates  most  where  the  subcutaneous 
tissue  is  loose,  so  here  the  oedema  is  greatest  where  the  sub- 
mucous tissue  is  loose.  The  mucous  membrane  of  the  larynx 
is  mostly  bound  down  pretty  firmly  to  the  subjacent  struc- 
tures, it  is  loose  over  the  epiglottis,  but  especially  in  the 
aryteno-epiglottidean  folds.  Accumulating  there,  the  fluid 
swells  up  the  mucous  membrane  ;  the  epiglottis  is  often  very 
prominent,  and  the  afyteno-epiglottidean  folds  form  promi- 
nent rounded  tumors.  It  is  these  latter  which  obstruct  the 
larynx,  and  it  is  generally  easy  to  reach  and  incise  them  with 
the  aid  of  the  laryngeal  mirror.  The  vocal  cords  are  not  af- 
fected at  all. 

Growths  are  not  uncommon  in  the  larynx,  and  they  are 
often  situated  on  the  vocal  cords.  If  this  be  the  case  they 
alter  the  voice,  usually  making  it  hoarse.  If  the  growth  be 
on  the  cords  it  is  easily  seen,  elsewhere  it  is  not  so  distinct, 
especially  if  it  be  small.  Most  of  these  tumors  are  simple  in 
their  nature ;  but  sometimes  sarcomata  or  cancers  attack  the 
larynx,  especially  the  latter.  Cancers  are  mostly  epithelial 
here,  and  as  these  commonly  ulcerate  we  may  have  consider- 
able loss  of  substance,  as  well  as  great  alterations  from  the 
extension  of  the  disease. 

Paralysis  and  Spasm  of  the  vocal  cords — Alterations  in 
Cough  and  Voice.  If  the  patient  cannot  speak  above  a 
whisper,  and  the  vocal  cords  are  normal  in  appearance,  then 
there  must  be  paralysis.  The  paralysis  may  be  of  central 
origin,  as  in  cases  of  hysteria  and  loss  of  voice  from  ft'ight. 
In  that  case  the  cords  may  be  seen  to  move  pretty  freely 
during  inspiration,  but  on  attempting  to  vocalize  they  are 
not  tightly  stretched,  and  do  not  come  closely  in  contact.  It 
often  happens  that  such  patients  can  cough  well  enough,  and 
it  can  then  be  seen  that  the  cords  approximate  perfectly.  In 
cases  which  have  recovered  from  diphtheria  there  is  often  a 
paralysis  of  the  vocal  cords,  which  is  frequently  associated 


300        FAUCES,  LARYNX,  AND  NARES. 

with  paralysis  of  the  soft  palate,  and  it  may  be  of  the  pharynx. 
Of  great  interest  are  the  paralyses  which  are  traceable  to 
interference  with  the  nerves  supplying  the  laryngeal  muscles. 
These  are  mostly  unilateral,  although  it  is  not  impossible  for 
the  nerves  on  both  sides  to  be  coincidently  involved.  Aneu- 
risms of  the  aorta  often  involve  the  recurrent  laryngeal  nerve 
of  the  left  side.  As  this  nerve  supplies  all  the  intrinsic 
muscles  of  the  larynx,  these  will  be  affected  if  the  nerve  is 
involved.  The  aneurism  may  irritate  the  nerve,  and  bring 
on  spasm  of  the  muscles.  The  spasm  appears  to  extend 
readily  to  all  the  muscles  of  the  larynx,  so  that  violent  suffo- 
cative attacks  occur  from  the  vocal  cords  being  forcibly  closed, 
and  the  patieut  may  die  in  one  of  these  attacks.  The  pres- 
sure on  the  nerve,  on  the  other  hand,  often  induces  paralysis, 
and  this  paralysis  will  be  unilateral.  It  may  be  a  very  slight 
paralysis ;  the  patient  is  not  able  to  keep  his  glottis  firmly 
closed  during  the  violent  expiratory  effort  of  coughing,  and 
so  the  cough  has  a  peculiar  sound,  a  clang  due  to  the  cords 
being  brought  together,  but  going  violently  apart  before  the 
violent  pressure  of  the  air  behind.  In  this  case  laryngeal 
examination  may  detect  little.  The  cords  may  be  approxi- 
mated during  vocalization,  but  the  left  one  may  be  seen  to 
move  more  sluggishly  than  the  right.  In  these  cases  the 
voice  is  altered,  it  may  be  hoarse  or  peculiar,  but  not  gene- 
rally reduced  to  a  whisper.  Sometimes  complete  paralysis 
supervenes.  In  that  case  the  cough  is  not  clanging,  but  a 
loud  rush  of  air  is  heard  as  if  through  a  moderately  narrow 
aperture.  The  voice  is  reduced  to  a  whisper,  and  with  the 
laryngoscope  it  can  be  seen  that  the  left  cord  is  paralyzed. 
During  vocalization,  it  does  not  come  forward  to  meet  its 
fellow,  but  lies  motionless,  and  the  right  cord,  not  being  met, 
projects  beyond  the  middle  line.  Apart  from  aneurisms, 
similar  results  may  be  produced  by  tumors  or  other  morbid 
conditions  interfering  with  the  nerves  in  their  course.  Phthi- 
sis pulmonalis  may,  by  affecting  the  pleura  and  neighboring 
structures,  involve  the  recurrent  nerve,  either  on  the  right 
or  left  side.  The  tumors  which  mostly  interfere  with  the 
recurrent  nerve  are  those  in  the  chest,  but  it  may  be  involved 
in  the  neck  as  well,  or  the  pneumogastric  may  be  attacked 
before  it  gives  off  the  recurrent.  It  will  be  remembered, 
further,  that  spasm  of  the  glottis  is  a  comparatively  frequent 
affection  in  children  ;  this  condition  is  known  under  the  name 
of  laryngismus  stridulus,  and  it  also  occurs  in  whooping- 
cough  and  bronchial  phthisis. 


INVESTIGATION    OP    THE    NARES.  301 

INVESTIGATION  OF  THE  NARES. 

Rhinoscopy  consists  in  the  inspection  of  the  nares ;  this 
may  be  done  by  inserting  a  mirror  behind  the  uvula,  with 
its  surface  so  placed  as  to  reflect  the  image  from  the  posterior 
nares.  The  mirror  must  be  a  small  one,  not  more  than  five- 
eighths  of  an  inch  in  breadth,  and  it  should  be  bent  so  that 
its  surface  is  at  right  angles  with  the  stem.  It  is  generally 
necessary  also  to  use  a  tongue  spatula,  which  should  be  in- 
troduced further  back  than  usual.  The  patient  sits  with  his 
head  erect,  or  slightly  bent  forward,  and  the  light  of  the 
lamp  is  to  be  reflected  on  the  fauces  exactly  as  in  laryngo- 
scopy. The  tongue  having  been  depressed  with  the  finger 
or  a  spatula,  the  mirror,  after  being  heated,  is  introduced 
into  the  back  of  the  throat,  and  placed  so  that  its  surface 
forms  with  the  horizon  an  angle  of  130  degrees.  The  mirror 
may  be  conveniently  introduced  first  on  one  side  of  the 
uvula  and  then  on  the  other,  so  that  an  image  may  be  ob- 
tained of  the  two  posterior  nares  separately.  The  uvula 
often  obstructs  the  view,  and  so  does  the  soft  palate,  if  the 
distance  between  the  anterior  pillars  of  the  faucess  and  the 
wall  of  the  pharynx  be  too  short.  A  hook  has  been  devised 
for  raising  the  uvula,  but  it  is  in  most  cases  of  doubtful 
utility.  The  image  obtained  is  at  first  rather  difficult  to 
understand,  and  especially  so,  as  it  is  impossible  to  get  a  full 
view  of  the  posterior  nares  at  once,  and  it  must  be  taken 
piecemeal.  The  most  prominent  appearance  is  the  middle 
turbinated  bone ;  below  it,  is  the  inferior,  and  above  it, 
somewhat  in  the  distance,  the  superior.  The  septum  is  also 
to  be  seen ;  and,  by  moving  the  mirror,  the  trumpet-shaped 
extremities  of  the  Eustachian  tubes.  It  must  be  confessed 
that  the  examination  is  often  unsatisfactory;  and  those  who 
desire  to  follow  it  out  more  fully  should  consult  some  of  the 
special  works,  such  as  that  of  Morell  Mackenzie  on  the 
Laryngoscope. 

The  anterior  nares  may  be  examined  by  causing  the  pa- 
tient to  bend  his  head  far  back,  and  then  directing  the  light 
by  means  of  the  reflector  into  the  nostrils.  The  nostrils 
may  be  dilated  with  a  blunt  probe,  or  other  means.  A 
spatula  has  been  devised  for  dilating  the  nostrils,  and  so 
exposing  the  anterior  nares. 

Rhinoscopy  will  be  called  for  when  the   existence   of  a 
chronic  discharge  from  the  nares,  or  a  persistent  obstruction, 
directs  special  attention   to   these  parts.     Sometimes,  also, 
26 


302  FAUCES,    LARYNX,    AND    NARES. 

the  condition  of  the  openings  of  the  Eustachian  tubes  in 
deafness  may  be  discovered  by  means  of  rhinoscopy.  When 
a  view  of  the  nares  is  obtained  it  may  be  possible  to  observe 
any  undue  redness,  or  thickening  of  the  mucous  membrane, 
the  existence  of  ulcers,  the  proximate  source  of  discharges, 
&c.  The  existence  and  exact  seat  of  polypi,  which  fre- 
quently obstruct  the  passage,  may  also  be  discovered  by  this 
means. 

For  descriptions  of  the  methods  of  examining  the  Larynx  and 
Nares  reference  may  be  made  to  the  works  of  Morell  Mackenzie, 
Prosser  James,  Cohen,  and  Lennox  Browne;  the  last  gives  nume- 
rous colored  illustrations  of  the  appearances  seen  in  the  larynx. 
See  also  the  work  of  Sir  Duncan  Gibb,  and  the  article  on  the  Lai'ynx 
in  Reynolds's  System,  Vol.  IIL,  by  Morell  Mackenzie. 

Croup,  Diphtheria,  Scarlatina,  Retro-Pharyngeal  Abscess,  &c., 
are  discussed  very  fully  in  works  on  the  Diseases  of  Children. 


303 


CHAPTER  XI. 

DISORDERS  OF  THE  DIGESTIVE  SYSTEM.i 

The  Digestive  Organs  are  much  deranged  in  a  great 
many  diseases  of  a  general  nature,  as  well  as  in  local  affec- 
tions of  these  organs  themselves  ;  an  inquiry  into  their  state 
constitutes  an  important  part  of  nearly  every  case  as  a  matter 
of  diagnosis;  but,  perhaps,  the  prognosis  and  treatment 
depend  even  more  particularly  on  this  investigation.  Fevers 
and  inflammations  of  nearly  every  kind  affect  the  digestive 
functions  more  or  less  seriously,  and  many  cerebral  and  other 
nervous  disorders  likewise  do  so ;  general  constitutional  dis- 
eases, anaemia,  Addison's  disease,  leukemia,  &c.,  also  disturb 
them  more  or  less  profoundly.  Affections  of  the  kidney, 
uterine  disorders,  and  pregnancy,  frequently  declare  them- 
selves first  by  vomiting :  and,  of  course,  diseases  of  the 
oesophagus,  stomach,  bowels,  liver,  pancreas,  peritoneum  and 
mesenteric  glands,  necessarily  derange   the  digestive  func- 

'  General  Treatises  on  Medicine  may  be  referred  to  for  affections 
of  the  Stomach,  Bowels,  &c.  See  especially  Reynolds's  System, 
Vol.  II. 

Infantile  Diarrhoea,  Dentition,  and  some  other  disorders  referred 
to  in  this  chapter  are  discussed  more  fully  in  Treatises  on  Diseases 
of  Cliildren  ;  see  West,  Lewis  Smith,  &c.,  and  also  Eustace  Smith 
on  the  Wasting  Diseases  of  Infancy. 

Regarding  the  Stomach,  Indigestion,  &c.,  see  Wilson  Fox,  Cham- 
bers, Pavy,  Brinton,  Habershon,  and  Fenwick.  Brinton's  book  on 
Intestinal  Obstruction  is  also  very  valuable ;  see  also  Hilton  Fagge 
in  Gufs  Hospital  Reports  for  1869,  on  the  same  subject. 

Cobbold  on  Entozoa,  Murchison  and  Frerichs  on  Diseases  of  the 
Liver,  Bright  on  Abdominal  Tumors,  and  Habershon  on  Diseases  of 
the  Abdomen,  may  also  be  referred  to. 

Regarding  the  Teeth  and  Gums,  see  special  works,  such  as  those 
of  Coles,  Wedl,  and  Garretson,  and  the  chapters  on  these  subjects 
in  Holmes's  System  of  Surgery,  and  Reynolds's  System  of  Medicine. 
Hutchinson's  Memoir  on  Inherited  Syphilis  is  also  very  important 
in  this  connection. 

Many  disorders  connected  with  the  Mouth,  (Esophagus,  and  Rec- 
tum, are  treated  of  more  fully  in  surgical  works,  and  these  must  be 
frequently  referred  to.  Holmes's  System,  from  the  fulness  of  its 
articles,  is  particularly  valuable  to  the  physician  in  this  respect. 


304         DISORDERS    OF    THE    DIGESTIVE    SYSTEM. 

tions ;  affections  of  the  digestive  organs  may  be  either  pri- 
mary, or  perhaps  the  secondary  effects  of  mischief  in  contig- 
uous organs  (aneurisms,  abdominal  tumors,  &c.) 

This  complexity  in  the  etiology  of  digestive  disorders  ne- 
cessitates a  very  careful  investigation  of  the  different  groups 
of  symptoms ;  each  particular  disorder  has  often  to  be  scru- 
tinized in  respect  of  the  duration,  the  proximate  cause,  and 
the  relative  date  of  the  symptom  in  question. 

The  appetite  is  usually  more  or  less  impaired  (Anorexia) 
in  all  serious  diseases,  especially  in  those  with  high  fever  or 
other  acute  symptoms,  and  in  those  which  involve  the  diges- 
tive organs  in  a  direct  manner.  We  should  ascertain  the 
habitual  character  of  the  appetite  in  health  ;  we  also  inquire 
whether  there  is  any  remaining  desire  for  particular  kinds  of 
food,  and  what  these  are,  whether  the  appetite  is  capricious 
as  to  special  kinds  of  food  or  abnormal  articles,  or  at  different 
times  ;  whether  the  loss  of  a[)petite  is  associated  with  nausea 
or  loathing  of  food  ;  and  whether  actual  sickness  and  vomit- 
ing occur  on  attempting  to  overcome  this  repugnance.  Many 
influences  not  usually  thought  of  as  diseases  are  often  at  work 
in  causing  impaired  appetite  ;  grief  or  anxiety  and  depression 
of  spirits,  want  of  company  at  meal  times,  want  of  fresh  air 
and  exercise,  the  use  of  certain  drugs,  including  opium, 
chloral,  and  alcohol  (even  in  medicinal  doses),  are  often  re- 
sponsible for  the  Avant  of  appetite  complained  of  by  our  pa- 
tients. In  some  forms  of  nervous  disease  there  is  an  inordi- 
nate appetite  arising  from  a  sense  of  want  or  emptiness,  even 
very  soon  after  a  meal ;  and  in  Diabetes  also,  the  appetite  is 
often  excessive.  In  certain  states  of  bodily  and  mental  dis- 
order an  unnatural  appetite  (pica)  for  the  most  extraordinary 
articles  may  sometimes  be  noticed  (Chlorosis,  Pregnancy, 
Insanity.     Compare  Chapter  viii.,  p.  231). 

Thirst  is  a  very  frequent  complaint  in  all  diseases  associ- 
ated with  much  pyrexia ;  in  such  cases,  notwithstanding  the 
quantity  of  fluid  consumed,  the  urine  is  usually  scanty.  In 
several  ibrms  of  stomachic  derangement  also,  the  presence  of 
thirst  is  a  frequent  symptom,  and  in  such  cases  the  urine 
may  be  abundant  although  otherwise  normal.  In  certain 
forms  of  Bright's  disease,  and  particularly  in  diabetes,  tlie 
complaint  of  thirst  often  directs  our  attention  to  the  exami- 
nation of  the  urine,  and  in  such  cases  the  consumption  of  a 
large  quantity  of  fluid  is  usually  found  to  be  associated  with 
frequent  micturition  and  the  passing  of  a  large  quantity  of 
urine ;  the  further  examination  brings  out  abnormalities  in 


MUGUET. 


305 


tlie  specific  gravity,  and  also  as  regards  the  presence  of  albu- 
men or  sugar.  Particular  articles  of  diet  (salt  fish,  &c.)  often 
cause  temporary  thirst,  and  the  use  or  abuse  of  alcohol  is 
frequently  followed  by  more  or  less  thirst  and  dryness  of  the 
throat,  especially  in  the  morning. 

THE  STATE  OF  THE  TONGUE 

affords  valuable  indications  respecting  the  digestive  functions, 
es[)ecially  when  the  disorder  is  due  to  the  influence  of  con- 
stitutional disturbance  (the  presence  of  febrile  and  inflamma- 
tory disease).  Indeed,  the  progress  of  a  febrile  attack  can 
often  be  traced  both  in  its  increase  and  deline  by  correspond- 
ing changes  in  the  state  of  the  tongue.  (For  various  matters 
concerning  the  innervation  of  the  tongue,  including  articula- 
tion, see  pp.  148,  162,  104,  175.) 

The  presence  of  a  fur  or  coating  on  the  tongue  should  be 
described  as  to  its  extent,  wliether  the  edges  and  tip  are 
clean,  and  as  to  the  color  and  thickness  of  the  fur  which  is 
sometimes  very  dense.  Different  from  the  ordinary  coatings 
of  digestive  disorder  are  the  white  soft  patches  of  Muguet 
(Parasitic    Aphthae    or    Stomatitis,    popularly    known    as 


,^ 


Fig.  30. — Oidium  Albicans,  the  vegetable  parasite  of  M'lguet  or  Thrush 
(Keduced  from  Ch.  Kobin.) 


"  Thrush,"  "  Frog,"  &c.) ;  these  are  often  seen  in  children, 
especially  in  those  Avho  are  fed  artificially ;  but  they  may 
likewise  occur  in  others,  and  even  in  adults  suffering  from 
chronic  diarrhoea  and  exhausting  diseases  approaching  a 
termination;  these  white  spots  and  patches  are  found  also 

26* 


306         DISORDERS    OP    THE    DIGESTIVE    SYSTEM. 

on  the  mucous  membrane  of  the  cheek  and  throat ;  they  are 
due  to  the  presence  of  a  vegetable  parasite  (Oidium  albicans, 
see  Fig.  30),  which  may  be  seen  with  the  microscope,  after 
removing  such  spots  with  the  point  of  a  knife  and  digesting 
them  in  liquor  potasste.  (For  distinction  from  white  diph- 
theritic patches,  see  Chapter  x.,  p.  290.)  Very  much  i*arer 
than  this  is  the  presence  of  a  black  parasite,  seen  occasion- 
ally in  cases  of  phthisis  and  some  other  diseases.  The  dark 
streaks  on  tlie  tongue  and  buccal  mucous  membrane  observed 
in  Addison's  disease,  form  part  of  a  general  pigmentation. 

The  dryness  of  the  tongue  is  the  next  point  to  be  con- 
sidered. This  may  be  tested  by  applying  the  tip  of  the  finger 
to  it  as  well  as  by  looking  at  it.  The  dryness  may  exist 
either  with  or  without  coating.  In  advancing  typhus,  pneu- 
monia, surgical  fever,  &c.,  we  often  find  the  tongue  becoming 
dry,  brown,  and  hard,  so  as  to  be  not  unlike  roasted  leather. 
Along  with  this  we  often  see  sordes  on  the  gums  and  teeth. 
In  less  severe  or  receding  forms  of  the  same  condition,  the 
dorsum  may  be  dry  and  the  edges  and  tip  somewhat  moist. 
But  the  tongue  may  be  dry  in  whole  or  in  part  without  much, 
if  any,  fur,  in  which  case  it  has  a  red  glazed  appearance  ;  or, 
if  some  parts  are  less  dry  than  others,  we  may  see  streaks 
here  and  there,  and  perhaps  small  patches  of  fur  on  the  dor- 
sum ;  this  state  is  not  unfrequently  complicated  with  hacks 
or  cracks,  often  very  painful ;  a  similar  condition  frequently 
can  be  traced  further  back  in  the  fauces. 

The  red  raw  tongue  is  seen  in  certain  febrile  states  (es- 
pecially enteric  and  scarlet  fevers)  ;  this  may  succeed  the 
intensely  furred  condition  already  referred  to  ;  the  Avhole  of 
the  thick  coating  sometimes  disappears  with  great  quickness, 
leaving  a  very  red  moist  surface  exposed.  This  sudden 
desquamation  is  scarcely  so  favorable  as  a  slower  and  more 
gradual  cleaning.  This  red  raw  tongue,  in  such  a  case,  may 
become  dry  and  glazed  in  the  further  progress  of  the  fever. 

The  "  Strawberry  tongue"  is  characterized  by  great  dis- 
tinctness of  the  papilliae,  associated  with  considerable  red- 
ness, and  not  unfrequently  with  thick  white  fur  in  adjacent 
parts.  This  strawberry  tongue  is  common  in  scarlet  fever, 
not  usually  at  the  very  beginning,  but  after  some  days'  con- 
tinuance of  the  fever. 

Enlargement  of  the  circumvallate  papillce,  at  the  back  of 
the  tongue.,  is  not  uncommon  in  cases  characterized  by  vari- 
ious  dyspeptic  symptoms,  and  often  associated  with  a  pitted 
condition  of  the  tonsils. 


TONGUE.  301 

Little  blisters  on  the  tongue  (aphthfe),  and  various  degrees 
of  ulceration,  supply  the  evidence  of  the  ditferent  forms  or  de- 
grees of  stomatitis  (vesicular,  ulcerative,  gangrenous)  :  these 
are  often  associated  with  salivation,  fetor,  and  much  febrile 
disturbance. 

A  swollen,  sodden  appearance  of  the  tongue  with  very  dis- 
tinct indentations  on  the  edges,  corresponding  to  the  teeth, 
is  often  found  in  dyspepsia  of  various  kinds,  including  those 
connected  with  the  free  use  of  alcohol.  Swelling  of  the 
tongue  from  salivation  by  mercury  or  iodide  of  potassium 
occasionally  occurs ;  the  rest  of  the  mouth  participates  in 
this  action  :  the  mucous  membrane  of  the  cheek  opposite  the 
teeth  should  also  be  examined,  and  the  smell  of  the  breath 
likewise.  Glossitis  (from  this  or  other  causes)  may  lead  to 
swelling  of  the  tongue,  and  this  may  be  so  great  that  the 
tongue  cannot  be  kept  within  the  mouth. 

Swellings  under  the  tongue  (ranula),  and  hardness  or 
nodulation  from  syphilis  and  cancer,  belong  rather  to  surgery 
than  medicine. 

Nearly  all  of  these  last  named  alterations,  associated  with 
swelling  or  enlargement  of  the  tongue,  may  lead  to  difficul- 
ties in  speaking  and  swallowing ;  they  sometimes  render 
eating  or  drinking  painful  or  impossible. 

Paleness  of  the  tongue  from  antemia,  lividity  in  cyanosis, 
coldness  in  cholera  or  collapse,  and  patches  of  eccliymosis  in 
purpura,  are  further  points  of  an  obvious  character  which 
should  be  noted  when  present. 

In  examining  the  tongue  we  frequently  detect  a  foulness 
in  the  breath.  This  is  often  due  to  sore-throat,  bad  teeth, 
decomposing  particles  of  food  or  blood  iii  the  mouth  or  nose, 
ozfena,  and  gangrene  of  the  lung :  it  may,  however,  arise 
also  from  disorder  of  the  stomach  due  to  grave  febrile  dis- 
orders, to  prolonged  constipation  or  intestinal  obstruction,  to 
errors  in  diet,  to  particular  forms  of  dyspepsia  with  fetid 
eructations,  or  to  the  clironic  and  baneful  influence  of  alcohol, 
opium,  and  chloral.  Some  medicines  impart  a  disagreeable 
smell  to  the  breath,  and  among  these  the  garlic  odor  of  bis- 
muth may  be  mentioned  as  it  is  apt  to  be  overlooked  (due 
to  the  occasional  presence  of  tellurium  in  certain  parcels  as 
an  impurity).  Various  well  known  volatile  drugs  likewise 
aifect  the  breath. 


308         DISORDERS    OF    THE    DIGESTIVE    SYSTEM. 


VOMITING. 

Vomiting  should  be  considered  in  respect  of  what  appears 
to  be  its  immediate  cause  :  we  inquire  as  to  whether  it  is 
connected  with  anything  taken  into  the  system,  as  food, 
drink  and  medicine  ;  or  into  the  lungs  by  direct  inhalation, 
or  in  connection  with  emanations  of  various  kinds  ;  or  by 
absorption  through  the  skin,  or  through  cuts  and  abrasions  : 
the  possibility  of  poisoning,  intentional  or  accidental,  or  in 
connection  with  the  occupation  and  habitation  of  the  patient, 
must  not  be  forgotten.  We  inquire,  further,  whether  the 
vomiting  is  associated  with  the  position  of  the  patient,  in- 
duced, for  example,  on  moving  or  on  rising  from  bed ; 
whether  it  only  comes  on  at  particular  times,  as  in  the 
morning,  or  in  connection  with  coughing  ;  whether  it  is  asso- 
ciated with,  or  preceded  by,  sickness,  nausea,  or  pain  in  the 
stomach  and  liver,  or  connected  with  jaundice,  or  with  dis- 
orders of  the  bowels.  Vomiting  is  likewise  frequently  asso- 
ciated with  headache,  pain  in  the  back,  fever,  paralysis, 
convulsions,  insensibility,  dropsy,  disease  of  the  urinary 
organs,  and  disorders  of  the  menstruation.  "We  must  inquire 
in  certain  cases  whether  there  has  been  any  exposure  to  the 
sun,  any  injury  to  the  head  or  belly,  any  surgical  operation, 
or  any  other  obvious  fact  of  this  kind  in  the  previous  history 
of  the  patient. 

When  due  to  ingesta,  the  vomiting  may  be  immediate,  or. 
it  may  not  occur  for  a  few  hours :  some  assistance  may  be 
derived  from  the  known  tendency  of  the  patient  to  vomit 
readily,  or  after  certain  articles :  when  in  such  cases  the 
vomiting  is  not  immediate,  there  is  usually  some  period  of 
sickness,  of  coldness,  faintness,  or  giddiness  just  before  the ' 
vomiting  occurs,  and  there  is  often  a  history  of  some  pre- 
vious derangement  of  the  primce  vice,  perhaps  with  furred 
tongue,  constipation,  &c.  When  sickness  and  vomiting  are 
due  to  these  last-named  causes,  there  is  usually  great  and 
permanent  relief  from  the  emptying  of  the  stomach,  but 
.sometimes  improper  food  and  certain  medicines  (antimony, 
chloroform,  opium,  &c.)  set  up  a  more  prolonged  vomiting, 
due  probably  to  some  changes  being  induced  by  them  in  the 
digestive  organs  (gastritis,  jaundice,  intestinal  catarrh, 
dysentery,  &c.),  as  evidenced  by  the  other  symptoms  of 
these  complaints.  Allied  to  this  is  the  vomiting  induced  by 
the  use  of  rich  food  in  excess,  or  the  morning  sickness  so 
common  in  those  who  drink   alcohol  regularly  and  freely, 


VOMITING,  309 

although  perhaps  never  to  the  extent  of  causing  obvious  in- 
toxication, or  in  those  who  are  addicted  to  the  frequent  use 
of  sedatives.  The  vomiting  in  such  cases  may  be  due  to  a 
practice  long  continued  and  not  to  any  one  act  which  we 
can  name. 

When  the  stomach  has  been  upset  from  any  cause,  many 
things  irritate  it  which  would  not  otherwise  do  so :  when 
even  a  little  cold  water  is  almost  immediately  rejected,  we 
have  evidence  of  very  great  irritability  of  the  stomach. 

The  influence  of  the  recumbent  position  in  helping  to  ward 
off  sickness  and  vomiting,  applies  to  nearly  every  variety  of 
the  disorder ;  but  in  some  cases  the  effect  of  change  in  posi- 
tion is  very  great ;  in  uterine  flexions  and  in  pregnancy,  the 
erect  position  often  determines  vomiting  at  once,  and  this 
is  no  doubt  one  of  the  reasons  why  the  sickness  is  chiefly 
marked  in  the  morning  in  many  of  these  cases.  In  cases  of 
vomiting  due  to  abdominal  abscesses,  pei-itonitis,  and  general 
debility,  the  influence  of  position  and  the  importance  of  per- 
fect rest  after  swallowing  anything  are  often  very  marked. 
The  sickness  caused  by  the  rolling  of  a  vessel  at  sea,  by  rapid 
rotation,  &c.,  may  be  mentioned  in  this  connection,  although 
such  sickness  is  probably  caused  in  some  way  through  changes 
in  the  cerebral  circulation. 

The  pains  and  discomforts  associated  with  vomiting  are 
very  variable.  In  fevers  and  inflammatory  diseases  the 
vomiting  is  usually  accompanied  with  more  or  less  headache, 
and  often  with  pain  in  the  back,  and  a  feeling  of  soreness  in 
the  limbs,  or  with  general  malaise.  But  in  addition  to  this 
there  is  often  pain  in  the  chest,  over  the  liver  or  gall-bladder, 
the  bowels,  kidneys,  bladder,  ovaries,  uterus,  testicles,  &c., 
according  to  the  special  organs  attacked. 

Pain  in  the  stomach  itself  should  be  inquired  into  as  to 
whether  it  appears  immediately  after  a  meal  (as  is  common 
in  gastric  ulcer),  or  only  after  the  process  of  digestion  has 
actually  been  going  on  (dyspepsia)  ;  whether  the  pain  is 
associated  with  much  wind  in  the  stomach,  and  whether  it  is 
relieved  by  eructations,  or  by  the  act  of  vomiting.  This 
relief  is  often  very  marked  in  cases  of  dyspepsia  and  of  dila- 
tion of  the  stomach.  The  sense  of  sickness  or  nausea  usually 
precedes  vomiting  from  most  causes,  but  not  unfrequently  it 
is  absent  in  the  vomiting  due  to  cerebral  disease,  and  occa- 
sionally in  that  of  renal  disease,  so  that  "causeless  vomiting" 
should  always  be  considered  from  this  point  of  view.  Apart 
from  serious  cerebral  lesions,  morning  sickness  is  not  uncom- 


310         DISORDERS    OP    THE    DIGESTIVE    SYSTEM. 

nion  in  those  whose  brains  are  overtaxed  to  a  serious  extent. 
Vomiting  without  any  very  obvious  cause  is  also  found  in 
Addison's  disease,  Pernicious  anaemia,  and  other  constitu- 
tional disorders.  In  cerebral  disease  violent  headache  often 
accompanies  the  vomiting,  and  headache  is  very  often  asso- 
ciated with  the  sickness  and  vomiting  due  to  indigestion. 
The  combination  of  headache  and  vomiting  (both  in  extreme 
forms)  is  seen  in  the  nervous  affection  known  as  "  sick 
headache"  (^migraine),  but  in  this  case  the  headache  is  usually 
unilateral  (Jiemicrania),  and  the  duration  of  the  attack 
limited  to  a  few  days  at  most.  While  pain  in  the  back 
and  vomiting  are  common  in  all  febrile  affections,  such  a 
pain  with  very  marked  tenderness  in  the  spine  may  some- 
times denote  a  spinal  meningitis,  or  some  other  form  of  in- 
flammatory mischief  in  the  cord. 

Disorder  of  the  bowels  frequently  indicates  the  cause  of 
the  vomiting  with  which  it  is  associated.  Vomiting  is  often 
severe  at  the  beginning  of  summer  diarrhoea,  especially  in 
children,  and  it  is  common  also  in  cholera  and  dysentery  ;  it 
sometimes  accompanies  the  act  of  defecation.  It  is  likewise 
common  in  cases  of  prolonged  constipation,  whether  from 
general  disorder  of  the  digestive  organs,  or  from  serious  ob- 
structions with  the  attendant  inflammation,  due  to  hernia, 
internal  strangulation,  invagination,  &c.  Examination  of  the 
hernial  regions,  of  the  state  of  the  abdomen,  of  the  charac- 
ter of  the  vomited  matters,  and  of  the  stools,  if  any,  should 
never  be  neglected.  Severe  vomiting  and  diarrhoea  some- 
times occur  in  the  various  forms  of  peritonitis.  This  com- 
bination is  also  found  at  the  beginning  of  certain  cases  of 
malignant  scarlatina  and  measles. 

Irritation  of  the  fauces,  produced  by  choking,  or  by  an 
infant's  sucking  too  gi-eedily,  or  perhaps  by  an  elongated 
uvula,  or  by  coughing,  very  often  produces  vomiting.  Vari- 
ous forms  of  cough,  especially  when  associated  with  profuse 
expectoration,  are  apt  to  excite  vomiting.  The  paroxysms 
of  whooping-cough  are  often  terminated  by  an  act  of  vomit- 
ing. It  may  be  noticed  in  passing  that  severe  vomiting  and 
retching  may  set  up  a  form  of  coughing  and  hawking  which 
may  seem  again  to  induce  further  vomiting. 

Menstrual  irregularities,  uterine  flexions,  pelvic  inflamma- 
tions, and  other  forms  of  uterine  and  ovarian  disease,  ai'e 
frequently  responsible  for  severe  and  persistent  vomiting 
with  great  sickness.  Any  history  of  suppression  of  the 
menses,  within   the  child-bearing  period  of  life,  associated 


(ESOPHAGEAL    VOMITING.  311 

with  this  symptom,  shoukl  lead  us  to  consider  the  question 
of  pregnancy. 

In  the  vomiting  due  to  renal  disease  we  usually  have  im- 
^Dortant  assistance  from  the  state  of  the  urine ;  vomiting 
occurs  at  times  in  all  forms  of  kidney  affections,  but  the  pas- 
sage of  renal  calculi,  and  the  poisoned  state  of  the  system 
known  as  uraemia,  may  be  named  as  conditions  specially 
likely  to  give  rise  to  vomiting.  The  occurrence  of  vomiting 
in  connection  with  a  great  diminution  of  the  urine  in  renal 
disease  is  always  of  very  serious  import  in  this  respect.  The 
vomiting  and  other  alarming  symptoms  observed  in  retro- 
cedent  gout  may  likewise  be  mentioned  here. 

Vomiting  is  a  habitual  accompaniment  of  the  paroxysmal 
and  excruciating  pains  in  the  hepatic  region  due  to  the 
passage  of  gall-stones  ;  it  usually  precedes  the  jaundice  due 
to  this  cause.  A  certain  amount  of  vomiting,  indeed,  is  a 
common  precursor  of  jaundice  from  Avhatever  cause,  although 
it  is  occasionally  quite  absent.     (See  Jaundice,  p.  332.) 

The  quantity  of  matter  ejected,  and  the  sensation  of  sour- 
ness, burning,  bitterness,  fetor,  &c.,  experienced  during  the 
act  are  of  importance  in  judging  of  the  size  of  the  stomach 
and  of  the  changes  which  the  contents  of  the  stomach  have 
been  undergoing.     (See  Vomited  Matters,  below.) 

CEsoPHAGEAL  VoMiTiNG  differs  from  ordinary  gastric 
vomiting  in  the  relatively  small  quantity  which  comes  up, 
and  in  the  absence  of  effort  and  straining  during  the  act. 
It  bears  some  resemblance  to  the  sudden  emptying  of  an 
india-rubber  tube  on  removing  it  from  a  large  water  tap. 
It  occurs  in  cases  of  stricture  of  the  cesophagus,  especially 
when  there  is  dilatation  of  its  cardiac  extremity.  This  is 
almost  always  a  malignant  disease,  but  it  may  also  arise 
from  injuries  (burns  and  caustic  liquors). 

Vomited  Matters These  should  always  be  preserved 

for  inspection,  especially  in  cases  of  suspected  poisoning,  and 
when  the  vomiting  is  of  an  obscure  character. 

The  quantity  vomited  at  a  time  is  often  important,  as  it 
helps  to  reveal  the  size  of  the  stomach,  and  to  indicate  the 
extent  to  which  the  meals,  of  several  days  it  may  be,  are  re- 
tained. Excessively  large  quantities  are  ejected  in  cases  of 
dilatation  of  the  stomach  (due  to  cancer  of  the  pylorus,  or 
other  causes).  These  excessive  quantities  are  often  only 
ejected  at  intervals  of  two  or  three  days,  and  the  dispropor- 
tion between  the  amount  swallowed  on  a  given  day  and  the 
amount  vomited,  serves  to  indicate  the  retention  of  several 


312         DISORDERS    OF    THE    DIGESTIVE    SYSTEM. 

days'  food.  The  relatively  large  quantity  vomited  in  certain 
cases  after  the  swallowing  of  a  small  amount  of  bland  fluid, 
serves  usually  to  reveal  somewhat  serious  congestion,  if  not 
erosion  or  ulceration,  of  the  stomach.  The  "  coflTee  ground" 
vomiting  in  such  cases  is  due  probably  to  the  exudation  of 
blood,  whose  character  has  become  altered  by  the  juices  of 
the  stomach.     (See  black  vomited  matter,  p.  313.) 

Tlte  obvious  character  of  the  vomited  matters  often  ex- 
plains an  attack  of  vomiting,  as  when  we  find  unripe  fruit, 
undigested  pie-crust,  and  similar  articles  brought  up  by  a 
sick  child,  or  when  Ave  find  alcoholic  liquors  vomited  by  a 
drunken  man.  The  curdled  milk  vomited  by  infants  does  not 
necessarily  imply  an  undue  acidity  of  the  stomach,  but  the 
excessive  tenacity  or  solidity  of  the  curd  may  indicate  that 
the  particular  milk  given  cannot  be  digested. 

The  degree  of  digestion  undergone  by  the  ejected  matters 
may  be  important,  as  indicating  the  length  of  time  the  food 
has  been  retained.  Occasionally  a  recent  meal  is  retained 
while  former  meals  which  have  been  so  far  digested  are 
ejected,  owing  probably  to  their  being  more  fluid.  The 
character  of  the  matter  vomited,  as  experienced  by  the  pa- 
tient, especially  as  to  sourness,  bitterness,  fetor,  &c.,  is  some- 
times of  value  ;  the  smell  and  reaction  can  be  ascertained  by 
ourselves.  The  conjunction  of  great  acidity  in  the  vomited 
matters  with  alkalinity  of  the  urine  has  often  been  noticed. 

The  smell  is  valuable  as  assisting  our  recognition  of  the 
nature  of  the  matters  vomited.  It  is  further  of  great  import- 
ance when  the  odor  can  be  recognized  as  distinctly  fecal. 
Occasionally  various  forms  of  decomposition  simulate  this 
odor,  but  when  it  is  quite  unequivocal  it  indicates  some  form 
of  obstruction  or  strangulation  of  the  bowel,  or  some  fistulous 
communication  of  a  lower  part  with  a  higher  part  of  the  in- 
testine, or  with  the  stomach  itself.  The  yeasty  or  frothy 
appearance  of  the  vomited  matters  indicates  that  fermenta- 
tion has  been  going  on  in  the  contents  of  the  stomach.  This 
is  often  associated  with  the  odor  peculiar  to  this  process, 
so  that  the  smell  of  the  vomited  matter  and  of  the  patient's 
breath  resembles  that  of  a  barrel  of  beer  or  porter.  Torulaj 
and  sarcinte  should  be  searched  for  in  such  cases.  (See  Mi- 
croscopic Examination,  p.  313.) 

Blood  in  large  quantity  can  be  generally  recognized  as 
such.  It  is  usually  darker  in  color  and  less  frothy  than  that 
brought  up  from  the  lungs.  Large  hemorrhages  from  the 
stomach  are  commoner  in  simple  gastric  ulcer  than  in  cancer 


EXAMINATION    OP    THE    VOMITED    MATTERS.      313 


or  any  other  affection  of  this  organ.  Occasionally  large 
quantities  of  blood  are  vomited  from  the  opening  of  an 
aneurism  into  the  oesophagus,  but  such  an  accident  is  usually 
rapidly  fatal.  Blood  in  small  quantities,  causing  florid  streaks 
amongst  the  mucus  and  vomited  matters,  is  not  uncommon  in 
any  very  violent  attacks  of  vomiting  if  long  continued.  Such 
streaks  are  specially  apt  to  appear  in  cases  associated  with 
congestion  of  the  stomach  from  disease  of  the  liver  or  other 
causes.  Dark  fluids,  resembling  "  coffee  grounds^'  or  '■'■sooty 
ffuids,"  are  almost  always  composed  of  altered  blood,  acted 
on  by  the  digestive  juices.  Tiiey  are  found  frequently  in 
cases  of  cancer  of  the  stomach,  in  gastric  ulcer,  in  congestion 
of  the  stomach,  and  in  peritonitis  ;  their  occurrence  towards 
the  end  of  a  prolonged  labor  may  likewise  be  mentioned  here. 

Bile  in  the  vomited  matters  is  often  complained  of  when 
the  presence  of  the  altered  blood  just  referred  to  is  really 
meant.  Bile  is  to  be  recognized  as  a  greenish  or  yellowish 
viscid  fluid ;  it  may  be  vomited  up  in  any  case  where  the 
retching  and  straining  are  prolonged,  after  the  stomach  has 
been  emptied  of  its  contents. 

Pus  is  rarely  vomited  from  the  stomach,  although  very 
frequently  brought  up  from  the  lungs.  Occasionally  sub- 
mucous suppuration  of  the  stomach,  stricture  of  the  oesopha- 
gus, or  of  the  cardiac  orifice  of  the  stomach,  and  the  opening 
of  an  abscess  into  the  stomach,  may  give  rise  to  this  symptom. 

77ie  appearance  of  worms  and  of  shreds  of  hydatids  is 
important :  the  round  worm  (ascaris  lumbricoides)  is  the 
only  one  met  with  commonly  in  such  a  way.  It  is  occasion- 
ally vomited  by  children  during  illnesses  of  various  kinds, 
not  directly  related  to  the  presence  of  worms. 

The  Microscopic  Examina- 
tion OF  THE  Vomited  Matters 
reveals  muscular  fibres,  starch 
granules,  oil  globules,  and  shreds 
of  vegetable  tissue,  according  to 
the  diet  of  the  patient.  Crystals 
of  margarine,  &c.,  are  also  often 
seen.  Blood,  pus,  &c.,  may  be 
recognized,  if  their  structure  be 
not  destroyed  by  the  digestive 
fluids.  "  Cancer  cells"  can  sel- 
dom or  ever  be  recognized  as  such 
with  any  degre  of  certainty.  The 
growth  known  as  Torula  cereve- 
27 


Fig.  31. — Sarci'nm  Ventnculi, 
with  starch  granules,  and  oil 
globules,  from  vomited  matter;;. 
(Otto  Funke.) 


314         DISORDERS    OF    THE    DIGESTIVE    SYSTEM. 

sice,  or  the  yeast  plant,  is  often  found  in  fermenting  matter 
from  the  stomach  (see  Fig.  55,  Chap.  xiii.).  Sarcince  sliould 
likewise  be  searched  for  when  there  is  fermentation,  or  in 
cases  of  accumulation  of  the  contents  of  the  stomach.  (See 
Fig.  31.)  They  are  found  in  many  cases  of  dilatation  of 
this  organ,  from  whatever  cause,  in  ulcer  and  cancer  of  the 
stomach,  without  dilatation,  and  in  certain  cases  of  gastric 
catarrh.  Their  presence  or  absence  cannot  be  relied  on  in 
the  differential  diagnosis  of  these  atfections.  These  are  little 
square  structures  resembling  wool-packs,  from  which  they  take 
their  name.  When  found  in  the  stomach  or  its  contents  they 
ai'e  called  Garcince  ventriculi,  but  similar  structures  have 
been  found  in  the  urine  (see  Chap,  xiii.),  and  in  various 
other  fluids  of  the  body.  Digestion  of  the  vomited  matter  in 
liquor  potassfe  brings  out  the  appearance  of  the  sarcinse  some- 
what more  distinctly. 

For  the  appearance  of  Hooklets,  &c.,  from  Hydatids,  see 
Fig.  42.  Casts  of  the  gastric  follicles  have  been  described 
by  Dr.  Fenwick  as  occurring  in  vomited  matters. 

Eructations  and  Regurgitation  of  food  or  fluids  are 
to  be  considered  as  to  the  time  at  which  they  occur  with 
regard  to  meals.  A  certain  amount  of  regurgitation  of  milk, 
after  sucking,  is  quite  natural  in  infants.  In  adults,  re- 
gurgitation may  occur  during  the  process  of  digestion ;  in 
such  cases  it  is  usually  accompanied  with  pain  and  excessive 
acidity.  (Pyrosis.)  There  may  be  such  an  appearance  of 
fluid  in  the  mouth,  however,  without  acidity ;  indeed  the 
fluid  Avhich  thus  ascends  from  the  stomach  may  be  quite 
bland  or  even  alkaline  ;  such  '' waterbrash"  is  always  an  in- 
dication of  digestive  disorder,  and  occasionally  of  serious 
lesions  of  the  stomach.  Apart  from  the  ascent  of  actual  fluid 
from  the  stomach,  the  patient  may  be  conscious  of  excessive 
acidity,  and  the  gas  belched  up  may  be  recognized  as  very 
sour. 

FLATULENCE  AND  HICCUP. 

Flatulence  manifests  itself  by  distension  in  the  region  of 
the  stomach  and  bowels,  causing  often  a  certain  amount  of 
pain  and  discomfort  in  these  situations,  relieved  to  some  ex- 
tent by  the  passage  of  wind  from  the  mouth  or  from  the 
anus.  Rumbling  noises  and  colicky  pains  often  attend  the 
passage  of  wind  along  the  intestinal  tract.  But  in  addition 
to  these  more  obvious  symptoms,  Avind  in  the  stomach  often 


FLATULENCE    AND    HICCUP.  315 

gives  rise  to  pain  between  tlie  shoulders,  or  aloout  the  heart, 
to  giddiness,  faintuess  for  a  minute  or  two,  to  palpitations  of 
the  heart,  &c. 

The  period  in  the  process  of  digestion  at  which  the  flatu- 
lence begins  to  appear  should  be  ascertained,  as  also  the  in- 
fluence which  certain  articles  of  diet  have  in  determining  the 
flatulence.  (Vegetables,  saccharine,  starchy,  and  fatty 
foods,  tea,  tobacco,  alcohol,  &c.)  The  peculiar  fermentation 
which  leads  to  the  production  of  gas  may  be  often  guessed  at 
by  the  description  which  the  patient  gives  of  the  taste  and 
smell  of  the  eructations,  or  perhaps  it  may  be  judged  of  by 
the  observer.  The  lactic  acid,  the  butyric  acid,  and  the  al- 
coholic fermentations  are  the  commonest. 

The  repeated  passage  of  wind  from  the  bowel  in  cases  of 
intestinal  obstruction  serves  to  show  that  the  obstruction  is 
not  absolute.  The  suppression  of  the  passage  of  wind  leads 
in  such  cases  to  excessive  tympanitic  distension  of  the  abdo- 
men, if  the  seat  of  obstruction  be  low  down. 

In  addition  to  intestinal  obstruction,  the  accumulation  of 
wind  in  the  bowels  is  commonly  observed  in  peritonitis,  both 
acute  and  chronic  (puerperal,  traumatic,  and  tubercular,  as 
well  as  other  forms).  In  enteric  fever,  a  certain  degree  of 
tympanites  is  habitual,  and  in  various  adynamic  states  it 
often  assumes  alarming  characters.  In  diseases  of  the  liver, 
and  in  ascites  resulting  therefrom,  such  flatulent  distension 
is  often  most  distressing.  In  rickets,  and. in  some  forms  of 
infantile  disease  characterized  by  digestive  derangement, 
distension  of  the  bowel  is  so  habitual  as  to  lead  to  a  perma- 
nent enlargement  of  the  belly,  sometimes  simulating  more 
serious  disease.  Flatulence  in  the  stomach  and  bowels  is 
one  of  the  commonest  features  in  cases  of  hysteria.  The 
sensation  compared  to  the  ascent  of  a  ball  of  wind  to  the 
throat,  producing  a  sense  of  impending  suffocation,  is  often 
described  by  hysterical  patients  (globus  hystericus). 

Hiccuj)  is  common  as  appearing  readily  in  certain  persons 
after  eating  or  drinking ;  when  of  short  duration  it  is  seldom 
of  much  importance.  Protracted  duration  of  hiccup  is  al- 
ways a  serious  symptom,  especially  in  fevers  or  other  ill- 
nesses with  much  nervous  prostration,  in  diseases  of  the 
liver,  and  in  cases  of  intestinal  obstruction. 


316         DISORDERS    OF    THE    DIGESTIVE    SYSTEM. 


STATE  OF  THE  BOWELS— ABDOMINAL  PAIN. 

The  State  of  the  Bowels  has  to  be  noted  in  most 
cases.  In  healthy  subjects  the  bowels  act  about  once  in  the 
twenty -four  hours  :  certain  persons  have  two  motions  in  the 
day,  or  a  motion  only  once  in  the  two  days,  without  any 
real  departure  from  health.  In  children  the  motions  are,  as 
a  rule,  more  frequent  than  in  adults,  and  in  young  infants 
three  or  four  motions  in  the  24  hours  may  be  regarded  as 
normal.  In  judging  of  the  frequency  or  infrequency  of  the 
motions,  as  an  index  of  disease,  we  must  have  regard  to  the 
quantity  and  quality  of  the  food  used,  and  the  amount  of 
muscular  exercise.  Scanty  food,  or  the  use  of  food  that  can 
be  nearly  all  absorbed  Avithout  residue,  and  the  absence  of 
active  exercise,  tend  to  produce  scanty  and  infrequent  mo- 
tions. Constipation,  prolonged  beyond  3  or  4  days,  must  b(; 
regarded  as  an  abnormal  state  :  occasionally,  however,  there 
is  an  interval  of  nearly  a  week  between  the  motions  in  per- 
sons who  reckon  this  thiiir  natural  condition.  The  irequency 
of  the  motions  should  be  stated,  if  jjossible,  as  to  the  actual 
number  of  stools  in  the  24  hours  :  occasionally,  it  is  impor- 
tant to  know  whether  the  frequency  is  less  during  night,  and 
then  the  number  of  stools  by  day  and  night  may  be  given 
separately.  The  influence  of  certain  meals  may  often  be 
seen  in  determining  several  motions  at  particular  times,  al- 
though there  may  be  no  disturbance  afterwards.  In  childi-en 
this  is  often  so  marked  as  to  give  rise  to  the  erroneous  idea 
of  the  milk  just  swallowed  having  passed  at  once  through 
the  bowels.  The  influence  of  movement  and  exertion,  like- 
wise, may  sometimes  be  traced  in  the  same  way  ;  the  rela- 
tive frequency  of  the  stools  at  particular  times,  and  under 
particular  circumstances,  has  often  to  be  specially  noted,  in 
order  to  give  us  a  true  idea  of  the  state  of  the  case. 

Hie  consistency  of  the  motions  is  the  next  point  of  im- 
j)ortance,  but  this  falls  rather  to  the  section  on  the  character 
of  the  stools  (p.  319). 

The  degree  of  force  or  straining  during  defecation,  the 
presence  of  pain  in  the  bowels  (see  next  section),  the  force 
with  Avhich  the  motions  are  expelled,  the  passage  of  wind 
with  the  motions,  and  the  presence  of  faintness  or  sickness 
before,  during,  or  after  defecation,  are  all  points  which 
should  be  inquired  into,  particularly  in  cases  of  diarrhoea 
and  constipation,  and  of  partial  obstruction  of  the  bowel. 

When  motions  are  passed  in  hed  and  without  notice,  it 


ABDOMINAL    PAIN.  317 

should  be  ascertained  whetlier  this  arises  from  unconscious- 
ness, from  defective  sensibility  in  the  parts,  from  paralysis 
of  the  sphincters,  from  great  fluidity  of  the  motions,  from 
spasmodic  or  irregular  action  of  the  bowel,  from  inability  of 
the  patient  arising  from  pain  or  paralysis  to  effect  the  neces- 
sary movements,  from  idiocy  or  defective  intelligence,  from 
indifference,  or,  in  children,  from  want  of  training.  The 
intentional  or  wilful  soiling  of  the  bed,  so  as  to  mislead  or 
to  secure  attention,  should  also  be  remembered  as  an  occa- 
sional occurrence. 

Pain  in  the  Abdomen  and  Bowels — Pain  in  the 
region  of  the  bowels  is  of  such  importance  that  we  must  try 
to  discriminate  the  different  forms,  and,  as  we  cannot  say  at 
once  whether  the  pain  is  in  the  bowels  themselves,  or  in  ad- 
jacent organs,  we  must  consider  them  together. 

Tenderness  of  the  abdomen  may  be  general  or  local,  and 
all  degrees  of  tenderness  are  met  with.  Generalized  tender- 
ness is  found  in  peritonitis,  sometimes  to  an  extreme  degree, 
so  that  the  least  touch,  or  even  the  pressure  of  the  bed- 
clothes is  painful ;  the  most  extensive  peritonitis,  however, 
may  exist  with  but  little  tenderness ;  and  in  certain  puerperal 
cases,  and  in  the  chronic  forms  of  peritonitis  the  tenderness 
is  often  extremely  slight,  or  even  altogether  absent.  Apart 
from  wounds  and  other  injuries,  surgical  operations,  and 
childbirth,  we  find  acute  peritonitis  to  arise  most  frequently, 
perhaps,  from  perforation  of  the  stomach  and  bowels,  in  the 
course  of  gastric  and  intestinal  ulcers,  enteric  fever,  and 
affections  of  the  ctecum  and  vermiform  appendix.  Abscesses 
and  accumulations  of  various  kinds  may,  by  rupture,  pro- 
duce the  same  effect  (hepatic  and  i-enal  abscess,  hydatids, 
ovarian  cysts,  vertebral  abscess,  rupture  of  gall-bladder, 
ulceration  of  gall-duct).  Tubercular  deposits,  although 
commoner  in  chronic  peritonitis,  sometimes  set  up  an  acute 
attack.  The  previous  history,  the  mode  of  onset,  and  the 
other  concurrent  symptoms  must  here  guide  the  diagnosis. 

Sometimes,  however,  peritonitis  arises  without  any  obvious 
cause  (so-called  idiopathic).  Certain  cases  of  rheumatism 
affecting  the  abdominal  walls  are  not  easily  separable  from 
peritonitis,  as  tenderness,  fever,  and  vomiting  may  all  be 
present.  In  many  cases  of  hysteria  there  is  extreme  sensi- 
tiveness and  shrinking  on  touching  the  abdomen:  the  absence 
of  pyrexia  in  such  cases  usually  serves  to  negative  the  idea 
of  acute  inflammation. 

Localized  tenderness,   from    circumscribed   peritonitis,  is 
27* 


318         DISORDERS    OF    THE    DIGESTIVE    SYSTEM. 

found  particnlHrly  over  the  ca?cum  (2)erityphilitis^,  and  in 
the  neighborliood  of  the  uterus  (^jer//»e^r;7?'s,  pelvi -perito- 
nitis, &c.)  Occasionally  a  localized  peritonitis,  particularly 
over  the  liver,  is  found  associated  with  Bright's  disease, 
syphilis,  and  other  depraved  states ;  and  a  localized  perito- 
nitis is  said  to  be  sometimes  produced  by  embolic  lesions  in 
the  spleen. 

Localized  tenderness,  however,  may  likewise  be  due  to 
various  affections  of  the  abdominal  organs  tlxemselves  apart 
from  peritonitis:  we  aim  at  determining  the  site  of  the  ten- 
derness in  relation  to  the  organs,  and  at  discovering  any 
alterations  in  the  size,  position,  shape,  or  density  of  the  vis- 
cera in  question.  (Congestion  and  cancer  of  the  liver,  can- 
cer or  ulceration  of  the  stomach,  dilatation  of  the  gall-bladder, 
calculous  affections  of  the  liver  and  kidneys,  inflammations, 
dilatations  and  displacements  of  the  kidneys,  disease  of  the 
supra-renal  capsules,  inflammations  of  the  ovaries,  uterus,  or 
bladder,  and  aortic  or  other  forms  of  abdominal  aneurisms, 
may  be  mentioned  in  this  coimection.) 

Colic — spasmodic  and  painful  contraction  of  the  bowel — 
often  produces  pain  quite  as  great  as  that  of  peritonitis :  the 
parts,  however,  are  seldom  very  tender,  indeed,  pressure 
may  relieve  the  pain  :  the  temperature,  moreover,  is  usually 
natural.  In  severe  persistent  colic,  associated  witJi  consti- 
jjation,  the  question  of  lead  poisoning  should  be  considered. 
In  an  attack  of  abdominal  pain,  with  constipation  and  vom- 
iting, even  when  no  local  tenderness  or  tumor  is  complained 
of,  the  hernial  regions  should  be  carefully  examined,  at  least, 
in  patients  of  whose  history  we  are  ignorant,  and  the  ques- 
tion of  internal  strangulation,  invagination,  &c.,  must  be 
considered  before  resorting  to  energetic  cathartics. 

Abdominal  pains,  apart  from  any  evidence  of  peritonitis, 
intestinal  obstruction,  or  inflammations  of  the  viscera,  some- 
times occur  in  such  a  form  as  to  lead  to  the  diagnosis  of  ab- 
dominal neuralgia,  but  this  must  always  be  accepted  Avith 
the  greatest  reserve.  Affections  of  the .  mesenteric  glands 
(tubercular  and  malignant)  are  often  associated  with  severe 
pain  of  obscure  origin,  and  old  adhesions  of  the  intestines 
may  give  rise  to  pain  appearing  at  particular  times  in  con- 
nection probably  with  the  varying  position  of  the  bowel, 
without  any  recent  inflammation.  jS^euralgic  pains  referred 
to  the  region  of  the  groin  are  often  due  to  uterine  disorders. 
In  chronic  peritonitis  the  pain  varies  much  in  severity; 
there  may  be  extensive  disease  of  this  kind  without  any  re- 


APPEARANCE    OF    MOTIONS.  319 

markable  pain  or  tenderness  having  ever  been  noticed  by  the 
patient ;  variations  in  the  severity  of  the  pains  in  svich  cases 
depend  probably,  in  part,  on  the  dragging  of  adhesions,  as 
just  described,  occurring  particularly  in  connection  with 
vomiting,  with  the  action  of  the  bowels,  distension  of  the 
intestines,  &c. ;  fresh  attacks  of  acute  inflammation,  super- 
vening in  chronic  peritonitis,  may  sometimes  be  recognized 
by  the  pains  being  associated  with  a  special  local  tenderness, 
and  with  an  elevation  of  the  general  temperature. 

Abscesses  and  tumors,  especially  aneurisms  of  the  aorta, 
and  malignant  disease  of  the  abdominal  organs,  or  of  the 
bones,  often  cause  severe  abdominal  pains  during  the  early 
stages  at  which  their  existence  cannot  be  recognized  by  the 
most  careful  physical  examination. 

Pains  associated  with  defecation  are  of  various  kinds. 
When  there  is  only  slight  pain  just  before  the  bowels  act, 
passing  away  soon  after  the  motion,  it  is  of  but  little  conse- 
quence; it  is  very  common,  especially  in  all  forms  of  loose- 
ness of  the  bowels,  and  in  connection  with  the  action  of 
purgatives.  When  the  pains  are  more  severe,  of  a  griping 
character,  and  frequently  recurring,  considerable  importance 
is  to  be  attached  to  them.  Looseness  of  the  bowels  with 
such  pains  often  proceeds  from  the  irritation  set  up  by  im- 
proper or  undigested  food,  fruit,  &c. ;  in  dysenteric  diarrhfea 
and  dysentery,  the  pains  accompanying  defecation  are  usu- 
ally of  a  more  straining  character,  and  the  sense  of  the 
bowel  not  being  properly  relieved  is  usually  very  marked 
{tenesmus). 

Painful  defecation,  Avith  constipation,  is  commonly  due  to 
the  size  or  hardness  of  the  fecal  masses  being  such  as  to  give 
rise  to  pain  from  this  alone  ;  the  masses  are  sometimes  so 
hard  or  so  large,  and  the  rectum  so  much  paralyzed,  that 
even  painful  forcing  fails  to  dislodge  the  feces,  and  they  have 
to  be  softened  by  enemata,  or  even  scooped  out  mechanically. 
With  hard  masses  of  this  description  any  tender  parts  of  the 
rectum  and  anus  are  apt  to  be  rendered  exquisitely  painful ; 
inflamed  piles,  and  fissure  of  the  anus,  prolapse  of  the  rectum, 
and  various  forms  of  inflammation,  ulceration,  or  excoriation 
of  the  parts  may  be  mentioned  as  common  causes  of  exqui- 
sitely painful  defecation  :  a  careful  examination  of  the  parts 
is  often  necessary  to  avoid  serious  mistakes. 

Appearance  of  Motions The  motions  should  be  ex- 
amined as  to  several  points ;  the  most  important  of  these  will 
now  be  considered. 


320         DISORDERS    OF    THE    DIGESTIVE    SYSTEM. 

Consistency :  Ave  ascertain  Avhether  the  motions  are 
''formed,"  that  is,  possess  the  cylindrical  shape  of  the  bowel; 
the  diameter  of  the  pieces  of  fecal  matter  is  of  importance  in 
stricture  of  the  bowel,  as  in  certain  cases  they  are  found  to 
be  very  narrow,  or  perhaps  flattened  and  riband-like.  Some- 
what globular  masses  of  various  sizes,  usually  hard  and  dry 
(scybala),  are  often  found  in  cases  of  constipation  ;  such  pieces 
have  lost  much  of  the  moisture  and  air  naturally  contained 
in  feces  from  their  being  long  retained  in  the  pouches  of  the 
large  bowel.  Feces  long  retained  often  fail  to  float  in  water, 
on  account  of  this  loss  of  air.  If  the  motion  be  not  "formed," 
it  should  be  described  as  to  whether  it  has  the  consistence  of 
a  thick  or  a  thin  pultaceous  mass,*or  whether  it  is  chiefly 
fluid,  with  a  few  solid  masses  interspersed.  Fluid  motions 
are  often  described  as  resembling  "pea  soup"  (enteric  fever)  ; 
"rice  water"  (cholera)  ;  or  the  "  scrapings  of  meat"  (dysen- 
tery), &c. 

The  color  of  the  motions  is  sometimes  described  simply  by 
the  terms  dark,  light,  green,  black,  &c.  Occasionally  it  is 
indicated  by  reference  to  the  cause  of  the  color :  thus  we 
speak  of  much  bile  or  little  bile  being  present.  The  natural 
color  of  the  motions  is  derived  from  the  biliary  coloring  mat- 
ter; "clay -like"  motions  are  found  when  there  is  an  absence 
or  a  diminution  of  bile.  Melcena  :  black  motions,  from  altered 
hlood,  are  found  when  blood  is  mixed  with  the  motions  in 
such  proportions  and  at  such  parts  of  the  digestive  tract  as  to 
be  acted  on  by  the  gastric  and  intestinal  secretions  (gastric 
and  duodenal  ulceration,  intestinal  hemorrhage  from  portal 
obstruction).  When  the  hemorrhage  is  large,  from  whatever 
cause  this  may  arise,  the  blood  preserves  much  more  of 
its  usual  color.  "When  the  bleeding  is  from  piles,  fistula, 
polypus,  and  cancer  of  the  rectum,  or  from  other  lesions  of 
the  lower  bowel,  the  blood  in  the  motions  usually  retains  its 
typical  appearance  as  blood,  with  more  or  less  of  a  florid 
color.  Black  motions  are  not  at  once  to  be  presumed  to 
derive  their  color  from  altered  blood,  as  various  medicines 
render  their  motions  dark,  particularly  iron,  bismuth,  and 
charcoal,  and,  to  a  less  extent,  lead,  copper,  tannic  acid,  log- 
wood, and  some  others ;  as  logwood  stains  babies'  napkins, 
attention  is  sometimes  called  to  this  peculiarity.  Mercurials 
often  render  the  motions  darker,  but  this  is  partly  owing,  no 
doubt,  to  their  being  thus  rendered  more  bilious.  Motions 
with  what  looks  like  unmixed  and  unaltered  bile  (a  greenish, 


MUCUS    AND    PUS    IN    MOTIONS.  .     321 

yellowish,  glairy  fluid)  are  occasionally  seen.  Green  tfiotions 
are  very  common  in  infantile  diarrhoea  :  the  green  motions 
sometimes  persist  for  a  considerable  time  after  the  diarrhoea 
has  been  checked ;  motions  passed  with  a  yellow  color  some- 
times change  their  appearance,  so  that  the  napkins  may  be 
green  after  the  lapse  of  some  time  when  produced  by  the 
nurse.  Sometimes  the  motions  are  almost  ivhite,  not  unlike 
boiled  bread  and  milk.  In  children  the  motions  often  pre- 
sent a  curdy  appearance  and  possess  a  sourish  smell,  and  not 
unfrequently  undigested  masses  of  curdled  milk  are  found 
mixed  up  with  the  fecculent  matter. 

Mucus  is  passed  in  large  quantity  in  -some  cases  of  in- 
vagination of  the  bowel — large  quantities  of  glairy,  clear, 
gum-like  material  coming  away  with  little  or  no  fecal  mat- 
ter. Such  mucus  may  be  colored  with  a  little  blood,  or  as- 
sociated with  large  quantities  of  it.  Mucus,  usually  of  a  less 
transparent  kind,  is  found  more  or  less  in  cases  of  dysentery, 
and  in  such  cases,  a  little  bloody  mucus  may  constitute  the 
whole  of  a  motion,  voided  with  a  feeling  of  great  urgency, 
and  passed  with  much  pain  and  straining.  Other  forms  of 
mucous  discharge,  consisting  of  more  opaque  yellowish  flakes 
and  shreds,  are  passed  in  cases  of  catarrh  of  the  bowel,  and 
considerable  casts  of  parts  of  the  intestinal  tract  are  voided 
in  certain  cases  of  so-called  "mucus  disease." 

Shreds  of  mucus  are  often  spoken  of  by  patients  as  "skins," 
and  are  sometimes  confounded  by  them  with  portions  of  dis- 
integrated worms. 

Pus  in  the  motions  may  proceed  from  various  aflTections  of 
the  lower  bowel  just  named  in  connection  with  bleeding 
from  the  same  situation  (see  p.  320),  and  some  admixture  of 
pus  is  common  in  dysenteric  motions  and  in  the  afi"ection 
referred  to  as  intestinal  catarrh.  Inflammation  of  the  ctecum 
sometimes  result  in  the  discharge  of  pus  from  the  bowels. 

Various  abscesses  open  into  the  bowel,  and  may  thus  give 
a  coating  to  the  feces,  or  furnish  a  considerable  quantity  of 
pus.  Of  these  the  most  common  are  pelvic  abscesses,  con- 
nected with  childbirth,  or  at  least  with  affections  of  the 
womb;  but  abscesses  arising  from  the  kidney  and  other  or- 
gans in  the  abdomen,  and  even  psoas  abscesses,  occasionally 
burst  into  the  bowel.  Abscess  of  the  prostate  usually  opens 
in  this  way.  Sometimes  a  cancerous  tumor  breaking  down 
presents  something  like  a  purulent  deposit  in  the  feces.  Por- 
tions of  bowel  which  liave  sloughed  may  also  be  voided  with 


.^•29 


DISORDERS    OF    THE    DIGESTIVE    SYSTEM. 


the  motions,  visually,  however,  in  a  gangrenous  or  disinte- 
grated state.  This  occurs  in  certain  cases  of  recovery  from 
invagination  of  the  bowel. 

Worms  are  usually  seen  quite  readily  if  the  motions  are 
examined  at  all,  at  least  in  the  case  of  round  worms  (ascaris 
lumbricoides),  and  tape-worms  {tcBnice  of  various  kinds). 
Thread  worms  (oxyurides),  however,  require  to  be  looked 
for  more  closely,  as  they  are  small.  Their  movements, 
wdien  expelled  alive,  assist  in  their  recognition.  (See  Figs. 
32  and  33.)     In  the  case  of  tape-worms,  the  narrow  parts 


Fig.  32. — Oxyurides  Vermiculares, 
Female,  natural  size.  (After  Da- 
vaine.) 


Fig.  33. — Oxyurides  Vermicu- 
lares, magnified  five  times.  A, 
Male  ;  B,  Female.      (Leuckart.) 


should  be  specially  looked  for  and  preserved  for  scrutiny,  to 
see  if  the  head  of  the  parasite  is  included  in  the  mass.  The 
diiferent  kinds  of  tcEnia  may  be  recognized  by  the  appearance 
of  the  head,  and  by  the  microscopic  examination  of  the  pro- 
glottides w'itli  regard  to  the  arrangement  of  the  passages  in 
the  uterus,  with  the  ova,  &c.  For  this  purpose  one  or  two 
of  the  large  segments  are  placed  on  a  microscopic  slide  to 
dry  (after  immersion  in  strong  spirit)  so  as  to  be  rendered 
transparent.  The  Teenia  Solium  and  the  Taenia  Medioca- 
nellata  are  the  only  tape-worms  common  in  this  country. 
(See  Figs.  34-38.)  Round  w^orms  resemble  earth-worms  in 
general  appearance,  although  paler  in  color.  The  female 
worm  is  usually  about  the  length  of  the  page  of  this  book, 
•and  the  male  is  considerably  smaller  (400  mm.  and  2.50  mm. 
respectively  as  a  maximum).  When  dry,  how^ever,  they 
shrivel  up  to  some  extent. 

Portions  of  hydatids  are   sometimes  expelled  with  the 


WORMS    IN    MOTION. 


323 


motions.     Anything  resembling  these  should  be  preserved 
for  further  examination.     (See  Fig.  42.) 


Fig.  35. — Proglottides  of  the 
Tcenia  Solium,  magnified  twice, 
f^howiag  arrangement  of  uterus. 
(Leuckart.) 


Fig.  34  —Tmnia  Medioeanellata,  natural 
size,  showing  the  different  size  and  shape 
of  the  segments  in  the  various  parts.  (The 
Taenia  solium  resembles  this  in  general 
appearance:  for  distinction  sej  Figs.  35-38.) 
(Leuckart.) 


Fig.  36.— Proglottis  of  TcBnia 
Mtdiocanellata,  magnified, 
showing  the  arrangement  of 
the  uterus.  (Leuckart.) 


324 


DISORDERS    OP    THE    DIGESTIVE    SYSTEM. 


Fatty  matter  is  occasionally  found  in  the  motions  in  large 
'quantity,  and  has  been  noticed  in  certain  cases  of  disease  of 
the  pancreas.  Smaller  quantities  of  oily  material  may  be 
passed  from  the  inability  of  the  patient  to  digest  or  absorb 
the  fat  in  the  food,  or  the  oil  administered  as  medicine. 


Fig.  37.— Head  of  Tmnin  SnJi-m, 
armed  with  a  circle  of  booklets, 
showiQg  two  of  the  four  suckers. 
(Dr.  Cobbold.) 


Fig.  38. — Head  of  Tcenia  MecHocand- 
la'a  (not  armed  with  booklets),  showiug 
two  of  the  four  suckers.  (Drawn  by  Dr. 
John  Wilson.) 


Gall-stones  must  be  searched  for  in  the  Avay  described  else- 
where (see  Jaundice,  p.  337)  when  the  discovery  of  them  is 
important.  We  must  accept  the  statement  of  patients  as  to 
passing  gall-stones  with  great  reserve,  unless  they  can  be 
produced,  or  unless  they  have  been  found  in  the  way  de- 
scribed, as  hardened  feces  and  intestinal  concretions  are  some- 
times mistaken  for  them. 

Bones^  Coins,  Artificial  Teeth,  and  various  other  things, 
swallowed  by  accident,  are  often  found  in  the  motions  after 
very  variable  periods,  extending  sometimes  to  several  months 
after  the  accident.  Such  articles  are  often  more  or  less 
corroded  by  the  digestive  fluids,  and  the  animal  parts  are 
usually  greatly  diminished  in  bulk,  or  even  quite  absent. 
The  metallic  parts  acted  on  may  have  caused  discoloration  of 
the  motions  during  the  period  the  article  was  retained. 

The  Smell  of  the  Stools  is  sometimes  particularly  offensive, 
and  special  odors  can  sometimes  be  recognized  as  peculiar  to 
certain  conditions,  but  they  are  not  easily  described.    Amongst 


CONSTIPATION    AND    DIARRH(EA.  325 

the  most  oifensive  are  dysenteric  motions,  and  the  motions 
in  certain  forms  and  stages  of  enteric  fever.  In  the  diarrhoea 
of  chiklren  the  milk  sometimes  undergoes  a  peculiarly  offen- 
sive decomposition,  controlled  in  certain  cases  by  the  px"e- 
vious  boiling  of  the  milk.  In  jaundice  also  the  motions  are 
often  very  disgusting.  Sourness  can  often  be  recognized  as 
characterizing  the  motions  of  children,  and  such  motions  are 
often  distinctly  curdy.  The  odor  of  sulphuretted  hydrogen, 
present  in  natural  feces  to  a  variable  extent  according  to 
the  nature  of  the  food,  is  extremely  marked  during  the  in- 
ternal use  of  sulphur  and  some  of  its  compounds.  Other 
medicines  may  also  communicate  their  special  odor  to  the 
stools. 

The  Clinical  Significance  of  Constipation  and 
Diarrhoea  varies  extremely.  Slight  indications  have  been 
inserted  in  enumerating  the  different  symptoms,  and  the  fol- 
lowing hints  are  now  added. 

Constipation  is  extremely  common,  in  its  slighter  forms, 
in  connection  with  disorders  of  digestion,  especially  such  as 
proceed  from  nervous  causes,  worry  of  business,  irregularity 
in  habits,  &c.  But  similar  causes  lead  in  certain  subjects  to 
diarrhoea.  Alternations  of  constipation  and  diarrhoea  are 
common  in  certain  forms  of  gastro-intestinal  disorder,  and 
are  met  with  even  in  dysentery  and  enteric  fever.  Occasion- 
ally also  the  constipation  usual  in  cancerous  obstruction  of 
the  rectum  is  varied  by  a  profuse  diarrhoea. 

A  constipated  state  of  the  bowels  is  habitual  at  the  begin- 
ning of  many  febrile  disorders.  Pretty  obstinate  constipation 
is  so  frequent  at  the  beginning  of  meningitis  as  to  afford  an 
important  indication  of  its  onset.  Occasionally  a  pre-exist- 
ing diarrhoea  is  replaced  by  constipation  on  the  supervention 
of  meningitis.  Constipation  when  protracted,  especially  when 
associated  with  vomiting  or  hiccup,  and  abdominal  pain,  and 
swelling,  should  always  dictate  the  necessity  of  examining 
for  hernial  strangulation,  even  in  the  less  usual  situations,  or 
for  considering  the  question  of  internal  obstruction  in  its 
various  forms,  or  of  invagination  of  the  bowel.  Chronic  per- 
itonitis sometimes  leads  to  similar  symptoms.  Paralysis 
(paraplegia)  occasionally  gives  rise  to  constipation  of  such 
an  obstinate  character  as  to  suggest  the  idea  of  obstruction. 

Diarrhoea  attends  certain  febrile  states,  apart  from  any 

specific  intestinal  affection,  being  induced  in  some  way  by 

the  pyrexial  state,  or  the  depraved  condition  of  the  blood, 

and  perhaps  by  the  inability  of  the  patient  to  digest  the  food 

28^ 


326         DISORDERS    OP    THE    DIGESTIVE    SYSTEM. 

taken  in.  Even  in  healthy  states,  undigested  or  indigestible 
tood  gives  rise  to  looseness  of  the  bowels.  Poisonous  sub- 
stances often  produce  severe  diarrhoea.  In  addition  to  the 
well-known  cathartics  and  the  irritant  poisons,  certain  forms 
of  shell-fish  and  the  flesh  of  animals  in  certain  states  of  de- 
composition may  be  mentioned.  The  influence  of  impure 
water,  the  leaking  of  sewage  pipes,  the  emanations  from  foul 
drains,  and  tlie  climatic  and  other  influences  which  lead  to 
dysentery  may  be  mentioned  in  this  connection.  Cholera  in 
its  epidemic  form,  and  in  the  less  severe  forms  known  as 
British  or  autumnal  cholera,  and  Cholera  Infantum,  may 
likewise  be  referred  to  in  tliis  class.  The  scarlatinal  poison 
sometimes  manifests  its  early  presence  by  a  violent  diarrhoea, 
especially  in  malignant  cases.  Possibly  also  the  spontaneous 
looseness  seen  in  certain  stages  of  uraemia  and  in  puerperal 
fever  may  be  referred  to- a  similar  cause.  Enteric  fever  with 
(its  intestinal  lesion)  presents  an  intermediate  form  between 
the  foregoing  and  those  cases  of  diarrhoea  which  owe  their 
origin  to  tubercular,  catarrhal,  or  dysenteric  ulceration  of 
the  bowels.  Peritonitis  frequently  gives  rise  to  severe  forms 
of  diarrhoea. 

The  presence  or  absence  of  the  various  concomitant  symp- 
toms, and  the  results  of  the  physical  exploration  of  the  ab- 
domen must  be  relied  on  for  the  differentiation  of  these  forms. 

THE  TEETH  AND  GUMS. 

An  examination  of  the  teeth  affords  evidence  in  many 
cases  of  certain  constitutional  states,  as  well  as  of  various 
local  sources  of  disturbance.  The  number  of  teeth  differs 
in  the  first  and  the  second  dentition.  The  age  of  young 
persons  can  sometimes  be  estimated  from  the  state  of  the 
dental  development. 

FORMULA  OF  THE  MILK  TEETH. 

M,     Ci     \     G,    M,) 

The  order  of  tlieir  appearance  varies  somewhat.  As  a  rule  the 
lower  central  incisors  appear  first,  then  the  upper  central  incisors, 
and  then  the  lower  lateral  incisors.  The  following  may  be  given 
as  the  usual  order  and  date  of  their  appearance  : — 

Central  incisors,  about  the    7th  month. 
Lateral  incisors,  "  9tli      " 

First  molars,  "         15th      " 

Canines,  "         18th      " 

Second  molars,  "         24th      " 


THE    SECOND    DENTITION.  327 

The  order,  however,  is  sometimes  different ;  the  date  of 
the  appearance  is  sometimes  earlier,  and  often  much  later 
than  appears  above.  The  process  goes  on  by  little  starts, 
with  distinct  intervals  or  pauses  betAveen. 

Disorders  of  dentition Lateness  in  dentition  often  arises 

from  the  constitutional  derangement  known  as  rickets  ;  the 
disturbances  of  digestion,  and  of  the  general  health,  arising 
from  this  cause,  are  often  ascribed  erroneously  to  the  ills  of 
teething.  But  although  the  first  teeth  have  appeared  at  the 
usual  time  the  rickety  state  may  really  exist,  and  from  this 
cause,  or  from  the  occurrence  of  more  definite  attacks  of  ill- 
ness, the  normal  progress  of  the  dentition  may  be  arrested 
or  delayed  for  a  time.  Precocious  cutting  of  the  early  teeth 
is  often  followed  by  delays  in  the  subsequent  ones. 

During  the  process  of  teething  the  infant  has  usually  a 
great  increase  in  the  amount  of  the  saliva.  Various  disturb- 
ances of  the  health,  especially  diarrhoea,  cutaneous  eruptions, 
and  convulsions,  are  ascribed  by  the  public  to  this  process, 
particularly  when  the  dentition  is  delayed  or  irregular  in  its 
course ;  but  these  illnesses  are  sometimes  due  to  disorders 
produced  by  the  use  of  artificial  food,  which  is  very  often 
begun  about  this  time  ;  or  they  may  be  due  to  rickets  or  to 
some  other  vice  in  the  constitution  of  the  infant.  The  ad- 
vance of  the  teeth  is  characterized  at  times  by  great  tender- 
ness over  the  gums ;  in  other  cases  the  rubbing  or  squeezing 
of  the  gums  seems  to  afford  relief  or  satisfaction.  The  pro- 
minence of  the  gum  over  an  advancing  tooth  sometimes  give 
a  fallacious  idea  of  its  nearness  to  the  surface.  Such  appear- 
ances may  come  and  go  more  than  once  before  the  tooth 
comes  through.  We  can  seldom  safely  predict  the  speedy 
cutting  of  a  tooth  unless  the  sharp  edge  be  felt  under  the 
gum.  Any  unusual  heat  of  the  mouth,  any  increase  in  the 
salivation,  and  any  little  ulcerations  of  the  gums  should  be 
noticed  in  connection  with  the  teething  process. 

In  rickety  and  syphilitic  childi-en  the  milk  teeth  often  rot 
away  or  drop  out  prematurely.  The  same  also  happens  oc- 
casionally in  others,  probably  from  gastric  disorders. 

The  Second  Dentition  begins  with  the  appearance  of 
t\\e  first  permanent  molars,  and  this  pi'ecedes  the  shedding  of 
the  twenty  milk  teeth,  which  begin  then  to  fall  out  in  suc- 
cession. 


328         DISORDERS    OF    THE    DIGESTIVE    SYSTEM. 


FORMULA  OF  THE  PERMANENT  TEETH. 


Ms     B,     Ci     I,     C,     B3 


in  all. 


M3     B,     C,     I,    Ci     B, 

The  order  in  wliicli  tliev  make  tlieir  appearance  may  be  thus 
stated : — 

Anterioi-  molars,  at  the    7th  year. 

Central  incisors,  "  8th     " 

Lateral  incisors,  "  9th     " 

Anterior  bicuspids,  "  10th     " 

Posterior  bicuspids,  "  lltli     " 

Canines,  "  12t]i     " 

Second  molars,  "  12th  to  14th  j-ear. 

Third  molars,  "  18th  to  25th     " 

The  eruption  of  the  permanent  teeth  seldom  gives  rise  to 
much  local  or  constitutional  distiu-bance.  except  in  the  case 
of  the  "  wisdom  teeth  ;"  considerable  pain  and  swelling  some- 
times appear  in  connection  with  the  cutting  of  those  of  the 
lower  jaw  in  particular. 

The  shape  and  apjjearance  of  the  teeth  sometimes  afford 
important  indications.  Transverse  grooves  and  slight  pitting 
on  their  surface  are  supposed  by  some  to  indicate  a  scrofu- 
lous constitution,  or  at  least  the  presence  of  previous  derange- 
ments in  the  health. 

The  notched  teeth  described  bj  Hutchinson  afford  import 
ant  evidence  of  congenital  syphilis.  They  often  coincide 
■with  syphilitic  keratitis,  and  sometimes  with  nervous  deaf- 
ness and  other  forms  of  the  inherited  disease.  The  deformity 
affects  the  upper  central  incisors  most  frequently  and  most 
distinctly,  although  tlie  other  incisors  and  the  canines  may 

also  be  affected.  The  upper 
central  incisors,  in  a  typical 
case,  are  dwarfed  both  in 
their  length  and  breadth  ; 
the  atrophy  affects  the  mid- 
dle lobe,  giving  rise  to  a 

Fig  39. -Notched  Teeth -Malforma-  ^^^^^^.^^  ^^^^^j^  ^^  j^^  .  ^  . 
tion  or  permanent  teeth  found  iu  heredi-  .  ^  ,  .  , 

tary  syphilis.     (Mr.  Jonathan  Hutchin-       SOmetimCS  frOm    thlS  nOtch 

son.)  there  may  be  traced  a  shal- 

low groove  both  before  and 
behind.  These  changes  are  not  always  present  in  heredi- 
tary syphilis  ;  they  are  only  of  value  as  signs  in  the  case  of 
the  liermanent  teeth.  After  a  time  the  depth  of  the  notch 
may  be  lessened  through  the  wearing  down  of  the  edge,  but 


GRINDING    THE    TEETH.  329 

the    deformity  can    usually   be   detected  even    then.     (See 
Fig.  39). 

Caries  of  the  teeth  occurs  from  causes  not  fully  known, 
but  the  lingering  of  acescent  fluids  about  the  teeth,  arising 
from  the  decomposition  of  particles  of  food  in  the  mouth, 
seems  to  favor  this  destruction.  Caries  is  frequent  in  cases 
of  chronic  dyspepsia.  This  affection  of  the  teeth  sometimes 
accounts  for  the  fetor  of  the  breath  which  may  be  noticed ; 
this  might  be  erroneously  ascribed  to  something  else.  The 
condition  of  the  teeth,  likewise,  has  important  bearings  on 
the  diagnosis  of  facial  neuralgia,  pains  in  the  ears,  affections 
of  the  eyes,  &c. ;  the  pain  sometimes  radiates  from  the 
teeth,  not  only  all  over  the  face,  but  even  down  to  the  neck. 
For  a  proper  examination  of  the  teeth  in  this  respect  the 
assistance  of  the  dentist  is  often  very  desirable,  but  in  the 
absence  of  this  we  may  learn  something  from  detecting  some 
special  tooth,  obviously  rotten,  or  with  an  exposed  pulp, 
whicli  gives  rise  to  sharp  pain  on  pi-essing  it  or  probing  it. 
In  a  diffused  facial  neuralgia,  from  any  cause,  the  teeth  also 
may  participate  in  the  general  suffering,  so  that  we  must 
search  for  a  local  and  specialized  tenderness  of  one  or  two 
teeth  in  particular.  Neuralgia  seems  sometimes  to  be  set 
up  by  the  extraction  of  a  tooth — the  pain  being  recog- 
nized by  the  patient  as  different  from  that  of  the  previous 
caries. 

The  rottenness  or  the  absence  of  the  teeth  may  throw  im- 
portant light  on  dyspeptic  disorders,  or  even  on  the  impei-fect 
nutrition  of  a  patient.  Defects  in  the  teeth  may  prevent  the 
due  trituration  of  the  food  necessary  for  its  proper  digestion. 

Falling  out  of  the  teeth  occurs  in  connection  with  mer- 
curial salivation,  and  also  in  connection  with  scurvy.  The 
earliest  signs  of  these  appear,  however,  in  the  gums.  The 
teeth  also  fall  out  in  certain  cases  of  destructive  ulceration 
involving  the  gums  (noma).  The  milk  teeth  often  rot  and 
fall  out  prematurely  in  rickets  and  syphilis. 

Grinding  the  teeth  is  almost  habitual  in  certain  children, 
and  it  readily  occurs  in  others  when  the  stomach  and  diges- 
tion are  out  of  order.  Its  presence,  therefore,  is  not  to  be 
ascribed  at  once  to  the  irritation  of  worms,  although  this  is 
a  prevalent  popular  opinion.  No  doubt,  however,  it  is  fre- 
quently present  in  such  cases.  In  smallpox  and  some  other 
febrile  diseases  in  childhood  grinding  of  the  teeth  is  an  un- 

28* 


330         DISORDERS    OF    THE    DIGESTIVE    SYSTEM. 

favorable    indication.      Altliough    commonest    in    cliildhood 
this  symptom  is  not  unknown  in  adults. 

The  Gl'ms  are  often  spongy  and  their  edges  ragged  and 
irregular  in  those  whose  teeth  are  bad  and  neglected,  and 
wlien  the  tartar  is  very  abundant.  AVhen  these  causes  of 
irritation  exist  the  indications  from  the  gums  are  not  so 
valuable. 

Swelling  of  the  gums,  with  slight  tenderness,  constitutes 
one  of  the  earliest  indications  of  the  action  of  mercury.  The 
special  fetor  of  the  breath  due  to  mercury  and  the  occurrence 
of  salivation  usually  appear  also.  This  influence  is  produced 
whatever  may  be  the  way  in  wiiich  the  metal  enters  the  sys- 
tem. .Some  other  metallic  poisons  cause  something  of  the 
same  kind,  but  in  a  much  less  degree. 

The  blue  or  blackish  line  on  the  gums,  just  above  the  teeth, 
affords,  when  it  is  pronounced,  a  valuable  indication  of  lead 
poisoning.  When  it  is  present  Ave  must  inquire  for  the  history 
of  colic,  and  ascertain  if  any  exposure  to  the  deleterious  in- 
fluence of  lead  has  arisen  in  connection  with  the  water-supply 
or  the  occupation  of  the  patient. 

A  red  line  on  the  gums  is  regarded  by  some  as  an  indication 
of  a  phthisical  constitution  :  although  often  present,  no  great 
reliance  can  be  placed  on  its  indications. 

Very  spongy  gums,  with  submucous  hemorrhages,  are 
common  in  scurvy  ;  bleeding  readily  arises  from  slight  irri- 
tation of  the  parts ;  and  fetor  of  the  breath  is  also  usually 
present.  Slight  forms  of  scurvy  are  not  uncommon  among 
laborers  who  carry  their  food  to  their  work,  and  live  on  tea, 
bread  and  bacon,  &c.  Subcutaneous  hemorrhages,  &c.,  must 
be  looked  for.  Purpura  likewise  affects  the  gums  in  a  way 
somewhat  similar  to  scurvy,  and  hemorrhages  sometimes 
arise  from  them  :  these  may  prove  serious  from  their  per- 
sistence and  the  difficulty  of  stopping  the  bleeding. 

Inflammation  of  the  gums  may  form  part  of  a  general 
affection  of  the  mouth,  already  described  (vesicular,  ulcera- 
tive, and  gangrenous  stomatitis  ;  see  p.  307).  The  local 
inflammation  and  swelling  known  as  "gum-boil"  arises  from 
inflammation  around  the  root  of  the  tooth  affected  (Periodon- 
titis) :  the  tooth  is  often  felt  to  be  tender,  and  sometimes  to 
be  elevated,  as  it  were,  from  the  socket.  The  local  disturb- 
ance, as  manifested  by  swelling,  and  the  general  reaction  are 
often  extreme :  when  by  accident  the  swelling  is  not  con- 
siderable the  first  indication  of  the  cause  of  the  violent  symp- 


AFFECTIONS    OF    GUMS.  331 

toms  may  be  the  appearance  of  pus  by  the  side  of  the"  tooth. 
With  infiammation  of  the  gum  fi'om  any  cause  more  or  less 
salivation  is  frequent. 

The  presence  of  sordes  on  the  gums  and  teeth,  of  the  white 
patches  of  rauguet,  and  the  discoloration  of  Addison's  disease, 
have  been  noticed  elsewhere  (see  pp.  305  and  .317).  Pallor 
of  the  gums  affords  a  valuable  indication  of  anaemia. 


332 


CHAPTER  XIL 

JAUNDICE  AND  DPtOPSY.» 

It  is  convenient  to  consider  these  aiFections  together,  as 
they  are  frequently  due  to  disease  of  the  liver,  and  it  is  not 
uncommon  to  find  them  both  in  the  same  patient.  But  it 
must  be  remembered  that  dropsy  is  frequently  due  to  other 
diseases  which  have  no  connection  with  jaundice  or  with  any 
form  of  hepatic  disease. 

JAUNDICE. 

When  jaundice  is  well  marked  there  can  be  no  mistake 
about  its  presence.  The  yellowness  of  the  skin  and  ocular 
conjunctiva,  and  the  discoloration  of  the  urine  with  bile, 
present  a  striking  and  easily  recognized  group  of  symptoms. 
Discoloration  of  the  skin,  somewhat  resembling  jaundice,  is 
found  in  certain  cases  of  anfemia,  in  chlorosis,  in  Addison's 
disease,  and  in  the  chloasma  associated  with  fibroid  tumors 
and  other  disorders  of  the  womb.  Exposure  to  the  sun  and 
weather  may  produce  in  certain  complexions  a  tinge  resem- 
bling jaundice,  and  the  serious  disturbances  of  the  general 
health,  induced  by  intermittent  fevers,  by  the  presence  of 
malignant  disease,  and  by  syphilis,  all  resemble,  at  times, 
the  cutaneous  discoloration  of  jaundice.  All  these  may 
usually  be  seen  to  differ  from  the  jaundice  tint  on  a  critical 
examination ;  and  in  nearly  all  these  affections  the  whiteness 
of  the  conjunctiviB,  which  often  indeed  shine  out  with  a 
pearly  brightness,  removes  the  cases  at  once  from  this  cate- 

'  The  works  of  Murcliiison  and  Frericlis  are  of  great  value  in  tlie 
study  of  the  affections  dealt  with  in  this  chapter. 

The  subject  must  be  considered  also  in  connection  with  the  sec- 
tion on  the  Physical  Examination  of  the  Abdomen,  Chapter  xvi., 
Part  3,  and  the  works  referred  to  there,  including  treatises  on  Ova- 
rian Disease  by  Spencer  Wells,  &c. 

The  books  referred  to  in  Chapter  xiii.  on  urinary  and  renal  dis- 
eases must  likewise  be  consulted  ;  and  works  on  diseases  of  children 
are  of  special  importance  in  connection  with  infantile  jaundice, 
tabes  mesenterica,  and  certain  forms  of  dropsy  affecting  the  young. 


OBSTRUCTIVE    JAUNDICE.  333 

gory.  The  conjunctiva,  however,  sometimes  presents  aiiingy 
yellow  color,  apart  from  jaundice,  this  being  due  to  the  pre- 
sence of  yellow  subconjunctival  fat,  and  this  complication 
presents  a  serious  difficulty  in  determining  the  presence  or 
absence  of  a  slight  discoloration  ;  but  when  the  color  is  due 
to  this  cause  it  is  usually  more  localized  to  special  parts,  and 
not  so  evenly  diffused  as  in  jaundice. 

The  urine  comes  to  our  aid  in  such  doubtful  cases,  for  it 
very  readily  assumes  the  jaundiced  color.  The  method  of 
testing  for  bile  pigment  is  described  in  the  section  on  urinary 
examinations  (see  Chapter  xiii.).  No  great  reliance  can  be 
placed  on  the  reports  of  patients  regarding  bile  in  the  urine, 
as  they  often  mistake  bloody  or  concentrated  urine  for  bilious 
discoloration,  and  the  internal  use  of  santoin  or  rhubarb  may 
produce  a  certain  resemblance  to  bilious  ui'ine.  The  urine 
shows  the  presence  of  jaundice  earlier  than  anything  else, 
but  it  likeAvise  ceases  the  soonest  to  be  affected,  if  the  attack 
be  passing  off,  so  that  the  urine  may  be  free  although  the 
conjunctivfe  remain  really  tinged.  By  watching  the  skin, 
the  conjunctivas,  and  the  urine,  in  different  stages  of  the 
suspected  jaimdice,  we  are  seldom  left  in  much  doubt.  The 
urine  in  jaundice  is  often  turbid  from  mucus:  it  seldom  con- 
tains albumen,  but  usually  deposits  tube-casts. 

The  appearance  of  the  stools  renders  much  assistance  in 
the  study  of  jaundice,  for  while  everything  else  is  discolored, 
the  motions  are  often  free  from  bile,  presenting  a  paler  ap- 
pearance than  natural.  This  is  often  best  described  by  the 
Avord  "  clayey."  But  we  may  also  have  marked  jaundice 
with  much  bile  in  the  feces.  The  pale  color  of  the  feces  may 
thus  in  doubtful  cases  assist  the  diagnosis  of  jaundice,  but 
their  bilious  color  does  not  count  for  much  as  negativing 
jaundice.  The  motions  in  jaundice  arc  usually  costive,  and 
if  long  retained  in  the  bowel,  the  feces  are  often  highly  offen- 
sive, from  decomposition  going  on  within.  The  bile  acts 
normally  both  as  a  purgative  and  an  antiseptic. 

Obstructive  and  Nox-obstructive  Jaundice The 

presence  or  absence  of  bile  in  the  motions  aflFords  an  im- 
portant aid  in  classifying  the  cases  according  as  they  are,  or 
are  not,  due  to  obstruction  of  the  common  bile-duct.  If 
there  be  any  such  obstruction,  the  motions  are  pale  in  pro- 
portion to  the  depth  of  the  jaundice;  and  we  find  that  in 
cases  due  to  obstruction  the  jaundice  is  much  deeper  than 
where  no  obstruction  exists. 

The  ohstruction  may  be  due  to  something  within  the  duct 


334  JAUNDICE    AND    DROPSY. 

itself — thickened  walls  or  excess  of  mucus  give  rise  to  the 
form  culled  "  catarrlial,"  or  gall-stones  may  block  up  the 
channel,  or  the  ducts  themselves  may  be  the  seat  of  a  can- 
cerous growth.  Ulcers,  cicatrices,  foreign  bodies,  and  even 
worms  have  been  known  to  interfere  with  the  opening  of  the 
duct  into  the  duodenum,  and  catarrh  or  inflammation  of  the 
duodenum  may  likewise  do  so.  But  the  obstruction  may  be 
due  to  pressure  from  without,  by  a  tumor  (usually  malignant) 
in  the  pancreas  or  duodenum  ;  or  by  waxy  or  cancerous 
glands  at  the  fissure  of  the  liver ;  or,  a  tumor  connected  with 
the  liver  itself  may,  from  its  position,  compress  the  duct,  as 
in  the  case  of  a  cancerous  nodule,  an  abscess,  an  aneurism, 
or  a  hydatid  cyst ;  or  again  an  exudation  of  lymph  (peri- 
hepatitis) may  by  its  contraction  constrict  the  duct.  Abdo- 
minal tumors  connected  with  the  kidney,  ovaries,  &c.,  may 
compress  tlie  bile-duct  and  give  rise  to  jaundice.  The  preg- 
nant uterus,  or  fecal  accumulations  in  the  bowels  may  like- 
wise do  so;  and  hardened  scybola  have  been  mistaken  for 
cancerous  nodules  in  cases  of  jaundice  due  to  such  a  cause. 

In  discriminating  these  causes  we  have  regard  to  the  size 
and  form  of  the  liver,  the  presence  and  character  of  the  pain 
(if  any),  and  the  special  symptoms  of  the  various  affections 
named,  in  their  relation  to  the  date  of  the  appearance  of  the 
jaundice.  In  cancer  the  liver  is  usually  enlarged,  often 
nodular,  more  or  less  painful,  and  tender  to  the  touch.  The 
occurrence  of  jaundice  is  due  to  the  accidental  position,  as  it 
Avere,  of  the  cancerous  mass,  and  so  it  may  be  an  early  or  a 
late  symptom,  and  indeed  is  often  absent  in  the  hepatic  cancer. 
Malignant  disease  elsewhere  is,  of  course,  a  strong  presump- 
tion in  favor  of  the  cancerous  origin  of  jaundice.  The 
persistence  or  variability  of  the  jaundice  is  important;  can- 
cerous jaundice  never  disappears  after  it  is  established ;  the 
history  of  pi-evious  attacks  of  jaundice,  therefore,  which  have 
passed  off,  predisposes  one  in  favor  of  a  less  serious  view  of 
the  case  ;  but  we  must  remember  that  in  rare  cases  the  pre- 
vious attacks  may  have  been  of  quite  a  different  nature  from 
the  existing  jaundice — thus  gall-stones  and  cancer  may  exist 
in  the  same  case.  The  concurrence  of  intense  jaundice  and 
pale  stools  with  abdominal  dropsy  may  be  regarded  as  point- 
ing to  the  obstruction  of  the  duct  and  of  the  portal  vein  by 
the  same  cause,  which  in  that  case  must  be  something  out- 
side of  both,  usually  a  cancerous  mass.  Slight  jaundice  may 
exist  along  with  dropsy  due  to  cirrhosis  or  to  congestion  of 
the  liver ;  the  jaundice  in  such  cases  is  not  only  usually 


DETECTION    OF    GALL-STONES.  335 

slight,  but  bile  is  not  absent  from  the  stools,  unless,  indeed, 
there  be  a  complication  from  catarrh  of  the  ducts  giving  rise  to 
obstruction.  Pain  is  an  important  symptom  in  the  study  of 
jaixndice.  Pain  is  usually,  but  not  always,  more  or  less  pre- 
sent in  cancer ;  even  in  catarrlial  jaundice,  with  perhaps  some 
congestion  of  the  liver,  there  is  some  pain  and  discomfort  in 
the  hepatic  region.  In  the  passage  of  gall-stones  the  pain 
reaches  a  maximum ;  it  is  very  violent,  paroxysmal,  and 
often  associated  with  great  sickness.  Such  paroxysms  of 
pain  may  occur  several  times  during  the  attack  of  jaundice, 
as  well  as  for  a  day  or  two  before  it  appears.  Occasionally 
the  jaundice  is  permanent,  the  gall-stone  being  permanently 
impacted  in  the  common  bile-duct ;  but  attacks  of  pain  and 
of  jaundice  from  gall-stones  are  apt  to  be  repeated  after  an 
interval  of  months  or  years.  (It  is  possible  to  have  an  at- 
tack of  biliary  colic  without  jaundice,  from  the  gall-stone 
escaping  quickly,  or  from  its  only  affecting  the  cystic  duct.) 
The  detection  of  gall-stones  in  the  motions  settles  the  diag- 
nosis. In  doubtful  cases,  where  there  is  a  suspicion  of  cancer, 
these  must  be  carefully  sought  for.  Althougli  dried  gall- 
stones float  in  water,  they  do  not  come  to  the  surface  on 
adding  water  to  the  feces  and  breaking  up  the  solid  masses. 
To  detect  them  we  must  pass  all  the  motions  througli  some 
form  of  sieve,  or  through  a  muslin  filter  after  pounding  them 
sufficiently  with  a  stick,  and  the  offensiveness  of  the  process 
maybe  lessened  by  adding  previovisly  some  disinfectant,  such 
as  Burnett's  or  Condy's  fluid.  If  there  is  any  doubt  as  to 
the  object  found  being  a  gall-stone,  a  portion  of  it  may  be 
pounded  and  dissolved  in  sulphuric  ether  or  boiling  alcohol, 
from  wdiich  crystals  of  cholesterine  are  deposited.  (See  Fig. 
43,  p.  347.) 

Rigors  occurring  in  jaundice  point  to  distension  of  the  bile- 
ducts  from  the  obstruction  of  gall-stones  ;  or  to  the  presence 
of  abscess  of  the  liver  ;  or  perhaps  to  the  existence  of  pynsmia 
of  which  the  jaundice  may  be  a  symptom.  Hemorrhages 
from  the  stomach  and  bowels,  and  subcutaneous  blotches 
occur  in  old  and  severe  forms  of  jaundice,  and  are  due  prob- 
ably to  deterioration  of  the  blood  in  cases  of  obstruction,  or 
to  blood-poisoning  or  portal  obstruction,  in  those  serious 
cases  where  there  is  no  obstruction  of  the  ducts  in  any  form. 
Hemorrhages  from  the  umbilicus  occur  in  some  serious  forms 
of  infantile  jaundice  (see  p.  336).  In  addition  to  the  symp- 
toms already  noticed,  itchiness  of  the  skin,  yellow  vision,  cu- 
taneous eruptions,  slowness  of  pulse,  a  lowered  temperatui'e 


336  JAUNDICE    AND    DROPSY. 

find  impaired  nutrition,  are  occusionally  very  noticeable. 
Sometimes  jaundice  appears  Avithout  anything  else  to  attract 
attention,  not  even  squeamishness  or  impaired  appetite. 
Popularly,  jaundice  is  often  ascribed  to  a- feeling  of  disgust 
produced  by  disagreeable  sights  and  smells,  but  probably  the 
incipient  jaundice  really  makes  the  person  more  squeamish 
than  usual  in  such  cases. 

Gases  of  jaundice  without  ohstruction  of  the  ducts  may  be 
due  to  various  poisonous  agencies,  animal,  vegetable,  and 
mineral,  including  under  this  name  certain  specific  fevers 
(relapsing  fever,  typhus,  pyaemia,  phosphorus,  copper,  chlo- 
roform, ether,  &c.).  Acute  atrophy  of  the  liver,  yellow  fever, 
and  epidemic  jaundice  may  also  perhaps  be  properly  classified 
under  this  heading.  Mental  and  nervous  disturbances  some- 
times produce  jaundice  ;  active  or  passive  congestion  of  the 
liver,  deficient  oxidation  of  the  blood,  chx'onic  atrophy  of  the 
liver,  and  imperfect  elimination  of  bile  from  protracted  con- 
stipation, may  all,  likewise,  give  rise  to  non-obstructive  jaun- 
dice. The  enumeration  of  these  causes  may  serve  to  direct 
our  inquiry  in  studying  cases  of  this  variety  of  jaundice  ; 
these  are  often  very  puzzling,  and  when  associated  with  cere- 
bral symptoms  very  alarming.  The  test  of  detecting  the 
biliary  acids  in  the  urine  has  been  proposed  as  an  assistance 
in  the  study  of  these  cases,  but  hitherto  without  much  suc- 
cess.    (See  Urine,  Biliary  Acids.) 

In  acute  atrophy  of  the  liver  the  jaundice  is  not  very  in- 
tense, but  it  is  persistent  ;  there  are  febrile  and  nervous 
symptoms  ;  the  hepatic  dulness  can  usually  be  made  out  to 
be  small,  but  the  liver  is  not  always  reduced  in  bulk  in  this 
affection :  crystals  of  tyrosine  may  sometimes  be  found  in 
the  urine  after  evaporation.  This  disease  is  specially  apt 
to  attack  women  and  to  be  associated  with  the  puerperal 
.  state. 

In  infancy  we  have  often  a  spurious  jaundice  due  to  mere 
discoloration  of  the  skin,  for  a  few  days  after  birth,  without 
any  affection  of  the  conjunctiva?.  A  true  jaundice  occurs 
not  unfrequently  from  catarrh  of  the  ducts,  and  sometimes 
from  imperfect  oxidation  of  the  blood,  especially  in  the  un- 
favorable surroundings  of  a  badly  ventilated  lying-in  hospital. 
A  very  serious  form  of  jaundice  occurs  in  infancy  associated 
with  an  unhealthy  state  of  the  umbilicus  (phlebitis,  peritonitis, 
pyaemia),  and  occasionally  with  congenital  defect  of  the  bile- 
ducts  :  this  malformation,  although  rare,  has  been  known  to 
occur  in  several  members  of  the  same  family,  and  has  been 


ANASARCA    AND    (EDEMA.  337 

known  to  occur  in  several  members  of  the  same  family,  and 
has  been  supposed  to  be  possibly  due  to  intra-uterine  syphilitic 
perihepatitis  :  this  defect  is  sometimes  associated  with  fatal  he- 
morrhages from  the  umbilicus  and  other  parts  :  the  jaundice 
appears  within  a  few  days  of  birth  and,  even  if  otherwise  un- 
complicated, leads  to  atropliy  and  death  within  a  few  months. 

DROPSY. 

Dropsy  must  be  studied  in  respect  of  its  severity,  its  ex- 
tent and  localization,  the  mode  of  its  onset,  and  the  evidence, 
if  any,  of  other  coexisting  diseases,  especially  of  disease  of 
the  heart,  liver,  kidneys,  spleen,  and  ovaries,  or  of  other 
swellings  or  tumors  in  the  abdomen  or  chest. 

Anasarca  and  QEdp^jia When  general  dropsy  of  the 

whole  body  (general  anasarca)  appears  somewhat  suddenly, 
the  common  cause  is  renal  disease  (nephritis).  In  sucli 
cases,  if  the  attack  be  not  too  sudden,  the  swelling  is  usually 
first  noticed  in  tlie  face  in  the  morning,  the  patient  feeling 
his  eyelids  stiff  and  heavy,  and  his  friends  noticing  a  degree 
of  puffiness  in  tlie  cheeks  and  around  the  orbits ;  this  often 
disappears  after  moving  about  for  a  time,  the  swelling  appear- 
ing in  the  feet  and  ankles  at  night:  this  in  its  turn  disap- 
pears with  rest  in  the  horizontal  posture — the  fluid  gravita- 
ting according  to  the  position  of  the  patient.  To  detect 
oedema  in  the  subcutaneous  cellular  tissue  we  press  firmly 
and  steadily  with  the  point  of  the  finger  and  observe  if  a 
"  pitting"  or  depression  remains.  We  select,  in  slight  cases, 
some  part  with  the  resistant  bone  beneath  to  bring  out  this 
pitting  more  easily.  In  extreme  dropsy  the  loose  areolar 
tissue  of  the  eyelids,  penis,  and  scrotum  become  specially 
distended.  The  testing  of  the  urine  usually  shows  such  a 
case  to  be  one  of  renal  origin  ;  pain  in  the  loins,  vomiting, 
and  more  or  less  shivering  are  common  in  acute  cases. 
Severe  renal  dropsy  has  been  known  to  exist  without  albu- 
minuria, but  this  is  rare ;  the  previous  history  of  scarlet 
fever,  &c.,  often  assists  the  diagnosis. 

QEdema  of  the  feet,  and  even  of  the  face,  closely  resem- 
bling renal  dropsy,  is  found  at  times  to  be  due  to  aneemia, 
the  altered  condition  of  the  blood  predisposing  to  these  exu- 
dations. The  urine  should  be  carefully  tested  more  than 
once  in  such  cases  before  deciding  on  the  absence  of  renal 
disease,  as  albumen  is  temporarily  absent  from  the  urine  in 
certain  cases,  especially  before  breakfast.  The  history  of 
29 


338  JAUNDICE    AND    DROPSY. 

fever,  floodings,  and  otlier  disorders  of  the  menstruation,  or 
o  previous  debilitating  diseases,  usually  supplies  an  intelli- 
gible cause  of  this  anaemia. 

(Edema  beginning  at  the  feet,  and  gradually  invading  the 
legs,  but  keeping  strictly  to  the  lower  limbs,  or  at  least  to 
the  lower  part  of  the  body,  is  usually  due  to  some  mechanical 
impediment  to  the  circulation  either  in  the  limbs,  in  the 
abdominal  vessels,  or  in  the  heart  itself.  Varicose  veins, 
thrombi,  aneurisms,  tumors,  or  anything,  such  as  a  bandage, 
pressing  on  the  veins  of  the  limb,  tumors  in  the  pelvis,  ab- 
dominal tumors  generally  (including  pregnancy),  glandular 
enlargements  (scrofulous  or  malignant)  in  the  neighborhood 
of  the  vena  cava,  and  similar  obstructions,  may  all  act  in  this 
way.  Nearly  all  the  forms  of  cardiac  disease  lead  to  some 
impediment  to  the  circulation,  so  that,  sooner  or  later,  oede- 
ma of  the  feet  is  apt  to  appear  (valvular  disease,  enlarged, 
weak,  and  fatty  heart).  When  such  dropsy  works  its  way 
up  to  the  abdomen,  the  inci  easing  pressure  on  the  renal 
veins  is  apt  to  set  up  congestion  of  the  kidneys,  and  this 
complication  may  cause  the  dropsy  to  assume  the  character 
of  general  anasarca.  Allied  to  this  oedema  from  mechanical 
impediment  or  feeble  circulation,  is  the  swelling  of  the  feet 
so  often  seen  in  old  people,  and  in  many  exhausting  diseases 
especially  before  death.  Chronic  renal  disease,  however, 
may  also  give  rise  to  dropsy  completely  limited  to  the  lower 
limbs. 

(Edema  of  the  dipper  part  of  the  body  may  be  but  part  of 
a  general  dropsy,  specially  appearing  in  the  dependent  parts 
of  the  trunk,  or  in  either  arm,  according  to  the  accident  of 
position  :  careful  observation  and  inquiry  as  to  the  posture  of 
the  patient  immediately  prior  to  our  visit  usually  explain  the 
variations  in  such  cases.  CEdema  limited  to  the  chest,  arms, 
neck,  or  face,  points  to  some  mechanical  obstruction  to  the 
circulation  within  the  chest,  giving  rise  probably  to  pressure 
on  the  veins.  Tumors  in  the  mediastinum,  especially  aneu- 
risms, cancers,  and  glandular  swellings  (lymphadenoma), 
must  be  remembered  in  this  connection  ;  the  discrimination 
of  these  must  be  sought  for  by  physical  signs  and  other 
symptoms. 

A  form  of  oedema  in  young  children,  affecting  chiefly  the 
dorsum  of  the  hands  and  feet,  but  occasionally  extending  to 
the  legs  also,  differs  from  that  usually  seen  in  adults  in  that 
it  does  not  pit  on   pressure ;  the   swelling  is  firm  and  the 


ASCITES.  339 

skin  drawn  tightly  over  it.  This  condition  is  met  vrith  in 
various  wasting  diseases,  chiefly  chronic  diarrhoea,  and  in 
connection  with  carpopedal  spasms  ;  it  always  serves  to  indi- 
cate a  serious  derangement  of  the  strength,  but  is  not  neces- 
sarily of  fatal  import ;  it  is  seldom  or  never  associated  with 
albuminuria,  and  seems  to  belong  rather  to  a  class  of  anaemic 
dropsies.  Allied  to  this  state  is  the  condition  described  by 
Underwood  as  "Hide  bound,"  and  by  the  French  writers  a; 
'''■  ScUrhne"  or  "  Induration  of  the  cellular  tissue." 

Abdominal  Dropsy  is  of  three  kinds :  fluid  in  the  cel- 
lular tissue  of  the  abdominal  walls  ;  fluid  within  the  perito- 
neal cavity  ;  fluid  within  some  cyst  in  the  abdomen,  usually 
of  the  ovary,  but  occasionally  of  the  kidney,  liver,  or  other 
parts. 

(Edema  of  the  abdominal  parietes  is  sometimes  so  con- 
siderable as  to  suggest  the  presence  of  fluid  in  tlie  perito- 
neum, with  Avhich  indeed  it  may  be  associated.  It  may  be 
due  to  the  causes  producing  general  dropsy,  as  already 
detailed,  but  when  it  seems  unduly  great  in  this  region  there 
is  usually  some  local  obstruction  to  the  return  of  blood  from 
the  veins  in  this  region.  This  oedema  is  discriminated  from 
ascites  by  the  test  of  "pitting,"  and  in  applying  the  pressure 
we  avail  ourselves  of  the  tissues  over  the  ribs,  or  over  the 
ilium  and  sacrum,  when  the  parietes  in  front  yield  too  much  so 
as  to  make  the  demonstration  diflicult.  This  oedema  changes 
somewiiat  with  position,  but  not  immediately,  as  in  the  case 
of  free  fluid  in  the  peritoneum,  only  after  the  lapse  of  some 
time. 

Fluid  in  the  Peritoneum — Ascites — may  be  of  inflamma- 
tory origin  (peritonitis  with  effusion,  including  tubercular, 
or  even  cancerous  peritonitis),  or  it  may  be  purely  dropsical 
in  its  nature  (hydro-peritoneum).  In  the  former  case,  the 
fluid  is  sometimes  partially  retained  in  meshes  of  lymph,  or 
hemmed  in  by  adhesions,  so  that  it  does  not  move  freely  with 
changes  in  the  position  of  the  patient ;  but,  as  a  rule,  all 
cases  with  much  fluid  in  the  peritoneum  answer  to  this  test, 
and  the  level  of  the  fluid,  seeking  the  most  dependent  parts, 
can  be  marked  out  by  percussion.  The  intestines,  unless 
bound  down  by  adhesions,  float  up  towards  the  umbilicus 
when  the  patient  lies  on  his  back,  giving  a  resonant  note  on 
percussion  there ;  but  if  the  fluid  accumulation  be  great, 
even  this  region  may  be  dull,  only  a  small  area  in  the  epi- 
gastrium yielding  a  clear  sound.  In  the  flanks  and  hypogas- 
tric regions,  in  like  manner,  the  percussion  note  is  dull  when 


340 


JAUNDICE    AND    DROPSY. 


Fig.  40. — The  shading  indicates 
the  position  of  the  Tercv-ssion- 
dulness  inacnseof  Ascites,  while 
the  patient  is  lying  on  the  hack, 
the  fluid  falling  to  the  low  levels 
in  the  flants,  and  the  nmhilical 
region  remaining  clear. 


the  patient  lies  on  the  back,  as 
these  regions  are  then  the  lowest ; 
hut  if  this  level  be  marked  and 
the  patient  be  turned  quite  round, 
first  to  the  right  side  and  then 
to  the  left,  the  line  of  dulness 
will  be  found  to  change  com- 
pletely if  it  be  due  to  fluid  freely 
movable  in  the  peritoneum — 
first  the  one  flank  and  then  the 
other  becoming  resonant,  and 
the  dulness  shifting  at  the  same 
time  to  the  parts  formerly  clear. 
Certain  difficulties  beset  this  test. 
Occasionally,  as  already  stated, 
the  fluid  and  the  bowels  may  be 
hampered  in  their  movements, 
and  so  the  changes  may  be  less 
definite.  Moreover,  when  the 
amount  of  fluid  is  small,  we  may 
be  unable  to  distinguish  the  dulness  in  tlie  flanks,  in  the 
midst  of  the  resonance  from  the  over-distension  of  the  intes- 
tines with  gas,  wliich  is  so  common  in  abdominal  dropsy. 
Qildema  of  the  integuments  often  interposes  an  insurmount- 
able barrier  to  the  detection  of  slight  ascites.  Sometimes 
by  pressing  away  the  oedema  from  a  portion  of  the  flank,  or 
by  getting  the  patient  to  lie  for  a  long  time  on  one  side,  we 
may  be  able  to  get  quit  of  this  complication  and  ascertain 
the  state  of  the  deeper  parts.  The  condition  of  the  abdo- 
minal viscera — a  loaded  colon,  an  enlarged  liver  or  spleen, 
the  presence  of  a  tumor,  of  the  gravid  uterus,  of  an  ovarian, 
an  omental,  or  some  other  cyst,  may  all  give  an  area  of  less 
movable  dulness,  and  impair  in  this  way  the  value  of  the 
test  by  change  of  posture :  most  of  these  complications  usu- 
ally exist  only,  or  chiefly,  on  one  side,  and  by  dipping  the 
hand  down  through  the  peritoneal  fluid  we  can  occasionally 
ascertain  the  presence  of  a  tumor,  and  so  make  allowance 
for  it. 

"When  the  quantity  of  fluid  in  the  peritoneum  is  small  we 
can  sometimes  recognize  its  presence  best  by  placing  the  pa- 
tient on  his  elbows  and  knees  :  the  umbilical  region,  quite 
resonant  during  examination  in  the  recumbent  posture,  may 
then  be  found  to  give  a  dull  note  in  this  altered  position. 
Another  test  for  ascites  is  the  detection   of  fluctuation. 


CYSTIC    DROPSY    OF    THE    OVARIES. 


341 


The  flat  hand  is  placed  on  the  side  of  the  abdomen,  and  with 
the  fingers  of  the  other  a  sharp  tap  is  directed  perpendicularly 
to  the  abdominal  walls  on  the  other  side,  when  a  distinct 
wave  is  often  both  seen  and  felt.  This  sign  varies  much  in 
distinctness  in  different  cases.  It  is  scarcely  available  except 
in  very  considerable  dropsy.  When  the  umbilical  ring  is 
protruded,  as  is  usually  the  case  in  extreme  ascites,  this 
fluctuation  is  often  well  felt  by  placing  the  finger  there. 
This  sign  of  fluctuation  may  be  obtained  in  the  various  forms 
of  fluid  accumulation  in  the  abdomen,  and  is  not  limited  to 
ascites.  Moreover,  when  there  is  great  flatulent  distension 
of  the  intestines,  with  tense  abdominal  walls,  a  feeling  closely 
resembling  fluctuation  is  sometimes  communicated  by  the 
air-filled  viscera,  without  the  presence  of  any  fluid  at  all. 
Of  course,  the  test  by  percussion  comes  here  to  our  aid,  but 
it  may  be  said  in  passing  that  if  the  bowel  be  greatly  dis- 
tended with  air  it  may  give  a 
dull  note :  this  happens  occa- 
sionally in  intestinal  strangula- 
tion. A  greatly  distended  blad- 
der sometimes  simulates  perito- 
neal fluid,  so  that  it  is  often  wise 
to  empty  the  bladder  by  the  ca- 
theter before  tapping  or  deciding 
finally  on  the  nature  of  the  fluid 
accumulation  :  in  the  case  of  a 
woman,  a  long  flexible  catheter 
should  be  used,  as  a  silver  female 
catheter  might  not  pass  through 
the  elongated  neck  of  the  bladder. 
The  mere  fact  of  a  patient  having 
recently  passed  urine,  does  not 
always  remove  the  necessity  of 
using  the  catheter  in  doubtful 
cases. 

Cystic  Dropsy  of  the  Ovaries 
and  other  forms  of  cystic  disease 
often  resemble  ascites,  and  they 
occasionally  exist  along  with  it. 
Ovarian  dropsy,  in  its  earlier 
stages  at  least,  usually  affects 
one  side  more  than  the  other, 
and  so  the  distension  is  not  always  symmetrical.  It  leaves, 
as  a  rule,  one  or  both  of  the  flanks  clear  on  percussion,  and 

29* 


Fig.  41. — Position  of  an  Ovarian 
tumor  of  the  right  side,  in  various 
stages  of  enlargement.  The  shad- 
ing indicates  the  Peroussion-dul- 
ness  in  Ovarian  Dropsy  of  mode- 
rate extfnt :  the  umbilical  region 
is  dull,  from  the  presence  of  fluid, 
and  the  flanks  remain  clear.  The 
outer  circle  shows  a  further  ex- 
tent to  which  the  dulness  may 
rei.ch  in  ovarian  dropsy.  (After 
Bright.) 


342  JAUNDICE    AND    DROPSY. 

gives  a  dull  note  in  front,  differing  thus  from  the  disposition 
of  the  dulness  in  ascites.  The  umbilical  ring  is  seldom  pro- 
truded, unless  there  be  coincident  ascites.  The  effect  of 
change  of  position  is  scarcely  appreciable  in  ovarian  dropsy, 
or  at  least  it  is  much  less  than  in  ascites.  Percussion  of  the 
lumbar  regions,  while  the  patient  rests  on  her  arms  and 
knees,  sometimes  assists  the  diagnosis  by  revealing  dulness 
over  the  diseased  ovary. 

Other  cystic  diseases  are  discriminated  from  ascites  in  a 
manner  similar  to  that  mentioned  in  connection  with  ovarian 
dropsy, — chiefly  by  their  position  and  by  the  fluid  not  being 
freely  movable.  Dilated  kidney  (hydronephrosis),  cystic 
disease  of  the  kidney,  and  parasitic  cysts  (hydatids)  of  the 
various  abdominal  organs,  including  the  omentum,  are  the 
chief  forms  of  encysted  accumulation  in  the  abdomen.  Oc- 
casionally very  soft  cancers  simulate  abdominal  dropsy,  and 
colloid  material  by  its  escape  into  the  abdominal  cavity  some- 
times gives  rise  to  a  semifluid  accumulation  there. 

Causes  of  Ascites — When  existing  alone,  or  out  of 
proportion  to  the  dropsy  elsewhere,  ascites  may  depend  on 
inflammatory  exudations  from  the  peritoneum,  or  on  mechani- 
cal obstruction  to  the  mesenteric  or  portal  veins.  (When 
associated  with  general  dropsy,  ascites  may  simply  form  a 
part  of  a  more  general  affection  ;  an  examination  of  the 
heart  and  of  the  urine  will  assist  the  diagnosis.) 

1.  Peritonitis  with  considerable  effusion  is  almost  always 
chronic  or  sub-acute.  The  tenderness  which  we  are  in  the 
habit  of  looking  for  in  inflammation  of  the  peritoneum,  is 
often  very  slight,  or  indeed  absent,  especially  if  there  be 
much  effusion :  these  cases  are  usually  due  to  tubercular  or, 
more  rarely,  cancerous  affections  of  the  peritoneum  :  in  the 
latter,  the  exudations  may  be  due  in  part  to  the  compression 
of  veins  by  the  cancerous  nodules,  and  in  part  to  the  inflam- 
mation set  up  :  this  inflammatory  element  may  account  for 
the  subsidence  of  a  dropsy  in  obviously  malignant  affections. 
By  applying  the  hand  over  the  abdomen  in  the  umbilical 
region,  and  by  wriggling  it  about  in  various  directions  and 
with  varying  pressure,  we  can,  at  times,  perceive  a  crack- 
ling sensation,  from  the  rubbing  together  of  rough  surfaces, 
or  from  the  presence  of  fluid  in  the  meshes  of  lymph  :  a 
similar  sense  of  friction  may  be  conveyed  to  the  hand  or  to 
the  ear  during  a  prolonged  act  of  inspiration  ;  care  must  be 
taken  not  to  confound  this  sensation  with  the  little  noises 
within  the  intestines  themselves.     When  such  friction  can  be 


ASCITES — PORTAL    OBSTRUCTION.  343 

made  out  in  a  case,  it  points  clearly  to   inflammatory  mis- 
chief.    Occasionally  peritoneal  friction  can  be  felt  or  heard  • 
over  the  liver,  and  is  developed  in  cases  of  abdominal  dropsy, 
especially  in  the  terminal  stages  of  renal  disease. 

As  chronic  peritonitis,  with  effusion,  is  usually  tubercular, 
considerable  assistance  may  often  be  derived  from  a  consid- 
eration of  the  age,  family  history,  and  general  aspect  of  the 
patient,  from  the  presence  of  evening  pyrexia,  and  from  the 
concurrence  of  other  symptoms  and  signs  of  tubercular  dis- 
ease— tabes  mesenterica,  ulceration  of  the  bowel,  pulmonary 
phthisis,  &c.  Cancer  is  usually  associated  with  but  little 
disturbance  of  the  temperature,  but  rapidly  developed  cancer 
of  the  peritoneum  may  run  a  febrile  course. 

2.  I'abes  mesenterica  is  a  cause  of  ascites  in  children 
which  must  never  be  forgotten  ;  but  it  is  not  so  common  as 
is  often  supposed  ;  tubercular  peritonitis  often  resembles  this 
form  of  disease,  and  the  large  belly  of  rickets  is  even  at  times 
confounded  with  this  formidable  disease.  Tabes  mesenterica 
is  rare  under  four  or  five  years  of  age.  The  dropsy  in  tabes 
is  usually  purely  abdominal ;  any  other,  if  present,  can  gen- 
erally be  made  out  to  be  quite  secondary  :  the  distension  of 
the  abdominal  veins  is  an  important  sign  of  this  form  of 
dropsy  in  the  young,  but  somwhat  similar  distension  is  seen 
in  malignant  growths  in  the  abdomen,  as  these  likewise 
obstruct  the  venous  circulation.  Occasionally  a  mass  of  large 
mesenteric  glands  can  be  felt  through  the  abdominal  walls. 
The  general  symptoms  of  wasting  disease,  and  the  occurrence 
of  evening  elevations  of  the  temperature,  the  presence  of 
pulmonary  phthisis,  the  existence  of  abdominal  pains,  of 
capricious  appetite,  of  occasional  disturbance  of  the  bowels, 
and  the  history  of  any  tendency  to  tubercular  disease  in  the 
family,  must  all  be  carefully  considered  in  doubtful  cases. 

3.  Portal  obstruction Disease  of  the  liver  causes  ascites 

from  its  affecting  the  portal  vein,  either  in  its  main  trunk  or 
in  its  ramifications  in  the  hepatic  structure.  Various  diseases 
of  the  liver,  as  well  as  other  affections  in  its  neighborhood, 
may  thus  give  rise  to  ascites ;  indeed,  anything  which  ob- 
structs the  portal  circulation  tends  to  give  rise  to  abdominal 
dropsy.  The  two  common  affections  of  the  liver  thus  asso- 
ciated with  dropsy  are  cirrhosis  or  atrophy  of  the  liver,  and 
cancer.  The  former,  when  extensive,  leads  to  the  oblitera- 
tion of  so  many  minute  branches  of  the  portal  vein,  that  it 
can  scarcely  fail  to  give  rise  to  dropsy,  but  in  cancer  much 
depends  on  the  accidental  position  of  the  malignant  nodule 


344  JAUNDICE    AND    DROPSY. 

. — whether  it  happens  to  press  on  the  large  veins — in  the 
production  of  tliis  symptom.  Along  with  cancer  of  the 
liver,  we  must  consider  cancerous  growths  in  the  pancreas, 
glands,  &c.,  in  the  neighborhood  of  the  vena  portze,  as  these 
can  seldom  be  separated  clinically  from  hepatic  affections. 
Perihepatitis  (by  compression  of  the  portal  vein  from  the 
contraction  of  the  lymph  effused  in  its  neighborhood)  like- 
wise causes  ascites  ;  and  occasionally  enlarged  glands  in  the 
fissure  of  the  liver  complicate  amyloid  disease,  and  give  rise 
in  this  w^ay  to  ascites.  Hydatid  cysts,  abscesses,  and  any 
tumors  or  swellings  in  the  liver  may  likewise,  from  their 
particular  positions,  give  rise  to  ascites.  Prolonged  conges- 
tion of  the  liver — whether  of  a  mechanical  nature,  as  seen 
in  long-standing  cases  of  heart  disease,  or  resulting  from  the 
pernicious  influence  of  alcoholic  stimulants — is  apt  to  lead 
to  induration  of  its  tissue,  and  obstruction  of  the  portal  cir- 
culation, and  so  gives  rise  to  peritoneal  dropsy.  Thrombosis 
sometimes  produces  a  rapidly  increasing  ascites,  and  this 
cause  should  be  considered  when  the  dropsy  suddenly  as- 
sumes an  alarming  form,  threatening  asphyxia  from  its  bulk ; 
it  is  usually  due  to  pre-existent  disease  in  the  liver,  or  other 
organs  concerned  in  the  portal  system,  but  it  occasionally 
arises,  as  elsewhere,  from  a  very  depraved  state  of  the  blood. 

In  investigating  these  causes  of  ascites,  we  try  to  discover 
the  size  of  the  liver  and  any  peculiarity  in  its  form. 

In  cirrhosis,  the  whole  organ  is  usually  small,  sometimes 
indeed  keeping  quite  within  the  margin  of  the  ribs :  occa- 
sionally, however,  it  is  not  diminished  in  size,  and,  perhaps, 
in  the  early  stage  it  may  even  be  unduly  large.  The  surface 
of  the  cirrhotic  liver  is  often  uneven,  with  little  projections, 
seldom  exceeding  a  pea  in  size ;  these  can  be  felt  in  some 
cases  on  moving  the  hand  from  side  to  side  over  the  organ, 
or  dipping  the  fingers  down  over  its  edge  ;  not  unfrequently 
there  are  certain  irregularities  in  the  tendinous  walls  of  the 
abdomen,  which  are  apt  to  mislead  us  in  such  examinations. 
These  nodules  in  cirrhosis  are  smaller  than  those  usually 
found  in  cancer.  The  spleen  is  generally  enlarged  in  cirrhosis 
of  the  liver,  but  this  can  seldom  be  made  out  if  there  be  much 
fluid  in  the  abdomen.  Jaundice,  in  a  pronounced  form,  is 
rare  in  cirrhosis,  but  the  patients  have  often  a  dingy  or  earthy 
complexion  ;  if  present  at  all,  the  jaundice  is  slight,  and  the 
bile  is  not  quite  absent  from  the  stools,  unless,  indeed,  there 
be  coincident  catarrh  of  the  ducts,  or  some  other  similar  com- 
plication.   Disturbance  of  the  stomach  and  bowels,  especially 


AiSCITES.  345 

vomiting  of  blood,  passing  of  blood  by  the  bowels,  the -exist- 
ence of  hemorrhoids,  the  occurrence  of  tarry  motions,  the 
habitual  presence  of  a  sediment  of  very  red  lithates  in  the 
urine,  obvious  imperfections  in  the  nutrition,  and  the  pre- 
vious history  of  spirit  drinking,  are  the  chief  points  to  be  in- 
quired for.  Spirit  drinking  is  the  common  cause  of  cirrhosis 
of  the  liver,  but  it  occurs  at  times  quite  apart  from  this  habit, 
and  has  even  been  seen  in  young  children.  Bleeding  from 
the  nose  and  subcutaneous  hemorrhages  are  also  occasional 
symptoms  in  cirrhosis  of  the  liver. 

In  cancer  of  the  liver,  the  whole  organ  is  usually  enlarged, 
but  sometimes  only  one  part  appears  affected  ;  the  surface 
often  presents  very  distinct  nodules  of  the  size  of  a  marble  or 
even  larger,  with  at  times  a  central  cup-like  depression  ; 
these  nodules  are  usually  painful  and  tender  on  pressure,  but 
cancer  of  the  liver  sometimes  runs  a  painless  course.  This 
affection  of  the  liver  is  generally  secondary  to  cancer  some- 
where else — if  judged  from  the  pathological  standpoint;  butj 
clinically,  it  is  often  impossible  to  get  evidence  of  any  other 
organ  being  affected,  and  even  when  the  liver  is  involved 
secondarily,  the  primary  cancer  may  be  in  the  gall-bladder, 
the  bile-ducts,  or  other  parts  intimately  related  to  the  liver. 
Careful  search,  however,  should  be  made  for  evidence  of 
cancer  elsewhere,  and  the  glandular  regions  should  be  ex- 
plored for  any  swellings.  Hereditary  tendencies  to  malig- 
nant disease  are  sometimes  traceable  in  the  family  history, 
but  they  can  but  seldom  be  made  out  even  if  really  present. 
Jaundice,  like  dropsy,  is  not  a  constant  sign  of  hepatic  cancer, 
but  when  deep  persistent  jaundice,  with  pale  stools,  coexists 
with  ascites,  it  adds  great  probability  to  the  diagnosis  of  a 
cancerous  mass  compressing  both  the  bile-ducts  and  the  portal 
vein. 

An  excessively  enlarged  spleen  is  sometimes  the  only  ob- 
vious cause  of  abdominal  dropsy. 

The  examination  of  the  abdomen  as  to  the  presence  of 
tumors,  or  even  as  to  the  size  of  the  liver  and  spleen,  is  often 
extremely  imperiect,  owing  to  the  distension  of  the  parts  by 
fluid  accumulation  ;  by  dipping  the  fingers  suddenly  down 
through  the  fluid  we  may  discover  an  enlargement  of  the 
liver  and  spleen,  which  might  otherwise  escape  notice. 
When,  however,  tapping  has  been  resorted  to,  an  opportunity 
is  afforded,  immediately  after  the  operation^  of  exploring  the 
parts,  owing  to  the  great  flaccidity  of  the  abdomen  ;  the 
spleen  can  often  be  thus  felt,  and  nodulation  of  the  liver  then 


346 


JAUNDICE    AND    DROPSY. 


discovered  ;  cancerous  masses  in  tlie  omentum,  peritoneum, 
or  mesenteric  glands,  can  often  be  easily  felt  at  tliis  time 
although,  perhaps,  in  no  other  way. 


/v  V 


N   S  X\V 


Fig.  42 — Human  Echinococci.  A,  A  group  of  echinococci,  still  adhering  to 
tlie  germinal  membrane  by  their  pedicles,  magnified  40  times  ;  B,  An  echinococ- 
cus  magnified  107  times  ;  the  head  is  invaginated  in  the  caudal  vesicle  ;  a  pedi- 
cle is  attached  to  it.  C,  The  same  compressed  ;  the  head  contracted,  the  suckers 
and  the  hooks  are  seen  in  the  interior.  D,  Echiuococcus  magnified  107  times  ; 
the  head  is  protruded  from  the  caudal  vesicle.  E,  Crown  of  hooks  magnified 
350  times.     (After  Davaine.) 

The  Examination  of  the  Fluid  removed  by  tapping 
may  likewise  lead  to  a  diagnosis  previously  doubtful,  but  ref- 
erence must  be  made  to  special  treatises  for  full  details  re- 
gardinor  these  various  fluids  and  their  characters.  The  fluid 
in  simple  dropsy  is  usually  clear,  with  a  specific  gravity  ot 
about  1012-1015,  it  contains  as  a  rule  but  little  blood, 
although  highly  albuminous  ;  bloody  serum  has,  however, 
been  observed  in  the  dropsy  due  to  portal  obstruction.  Asci- 
tic fluids  vary  much  in  specific  gravity  (1012-1035),  and 
alvso  in  the  quantity  of  albumen  which  they  contain.  In 
cases  of  cancer  the  fluid  may  be  of  the  same  character  as 
that  of  simple  dropsy,  even  when  the  disease  involves  the 
peritoneum,  but  in  cancerous  cases  blood  is  a  more  frequent 
constituent.  Lymph  (perhaps  blocking  up  the  canula)  indi- 
cates some  degree  of  peritonitis,  but  all  dropsies  are  liable  to 
set  up  a  certain  amount  of  inflammation  in  a  secondary  man- 
ner. A  hydatid  cyst — unless  contaminated  with  efi'used 
blood  and  the  products  of  inflammation — yields  a  clear  fluid 
of  low  specific  gravity  about  1007-1009,  without  albumen  or 


EXAMINATION    OF    OVARIAN    FLUIDS. 


34t 


urea,  and  with  abundance  of  chloride  of  sodium.  Moreover 
echinococci  or  booklets  may  usually  be  found  on  microscopic 
examination  (see  Fig.  42).  Urine  may  be  recognized  by 
its  odor  sometimes,  or  by  its  yielding  crystals  of  nitrate  of 
urea  on  the  addition  of  nitric  acid,  after  concentration  or  ex- 
traction with  alcohol.  Urea  may  also  be  found  in  the  drop- 
sical exudations  of  the  abdomen  due  to  renal  disease,  so  that 
this  test  is  chiefly  applicable  to  the  case  of  a  cyst.  Urine 
from  a  dilated  kidney  (hydronephrosis)  is  usually  of  a  very 
low  specific  gi'avity ;  it  may  contain  a  trace  of  albumen. 
The  possibility  of  complex  jiuids  from  the  rupture  of  cysts, 
the  effusion  of  blood,  and  the  products  of  inflammation  must 
be  rememb^ed  :  dark  chocolate  colored  fluids  with  shreds, 
&c.,  coming  away  on  tapping  are  usually  due  to  such  causes. 
Somewhat  dark  colored  fluids  sometimes  slightly,  some- 
times extremely  ropy  or  even  gelatinous,  are  common  in  ova- 
rian cysts.  In  such  cases  we  may 
often  see  glittering  specks  with 
the  naked  eye  shown  by  the  mi- 
croscope to  be  scales  of  choleste- 
rine  (see  Fig.  43).  These  are 
commonly  found  in  encysted  fluids, 
but  their  presence  has  been  re- 
corded in  chronic  inflammatory 
peritoneal  effusions  also  :  they  as- 
sist but  do  not  settle  the  diiferen- 
tial  diagnosis  of  ovarian  and  peri- 
toneal dropsy.  Ovarian  fluids  may, 
however,  present  a  close  resem- 
blance to  peritoneal  exudations  ; 
they  are  often  clear  and  sometimes 
of  low  specific  gravity  (especially 
in  parovarian  cysts).    The  specific 

gravity  of  ovarian  fluids  varies  from  1003-1045.  The  de- 
tection of  "  paralbumen"  in  abdominal  fluids  has  been  alleged 
as  diagnostic  of  an  ovarian  origin,  but  this  substance  has  now 
been  found  in  other  forms  of  disease.  "Paralbumen"  is  not 
precipitated  by  heat,  although  the  fluid  may  become  turbid. 
The  action  of  dilute  acetic  acid  assists  its  recognition  :  like 
mucin,  paralbumen  is  precipitated  by  this  reagent,  or  at  least 
a  turbidity  is  produced,  but  the  turbidity  due  to  mucin  is  not 
dissipated  by  excess  of  the  acid,  or  by  the  addition  of  a 
strong  solution  of  chloride  of  sodium,  while  the  turbidity  in 
the  case  of  paralbumen  is  dissolved  by  both  of  these  reagents. 


Fig.  43.— Crystals  of  Choleste- 
iue.     (Otto  Funke.) 


348  JAUNDICE    AND    DROPSY. 

Paralbumen  is  precipitated  by  alcohol :  so  is  a  substance 
named  "metalbumen,"  but  tliis  latter  again  is  not  precipita- 
ted by  ferrocyanide  of  potassium  and  acetic  acid  as  paralbu- 
men  is.  Some  confusion  exists  as  to  the  reactions  of  "  paral- 
bumen" :  the  various  forms  of  albumen  do  not  seem  as  yet 
sufficiently  well  demarcated.  Another  test  often  applied  is 
to  boil  the  fluid,  and  after  obtaining  a  coagulum,  to  add 
strong  acetic  acid  which  redissolves  the  precipitate  from  ova- 
rian fluids,  or  renders  it  gelatinous  after  it  is  shaken  up. 

Mixtures  of  ordinary  albumen  and  of  these  altered  forms 
no  doubt  frequently  occur,  and  tend  to  confuse  the  results  of 
the  tests. 

The  microscopic  examination  of  ovarian  fluids  reveals  in 
addition  to  the  cholesterine  crystals  already  mentioned  vari- 
ous cellular  structures,  pus,  blood,  epithelial  cells,  and  com- 
pound granular  masses.  Besides  these  Dr.  Drysdale  de- 
scribes a  granular  cell  regarded  by  him  as  peculiar  to  ovarian 
fluids.  It  resembles  a  pus  cell,  but  varies  in  size :  acetic 
acid  does  not  remove  the  granular  appearance  ;  with  ether 
the  granules  become  more  transparent,  but  the  cell  is  not 
otherwise  altered.  These  observations  require  further  veri- 
fication before  they  can  be  relied  on.  Some  pear-shaped 
cells  have  recently  been  described  by  Spencer  Wells  as  occur- 
ring  in  fluids  due  to  malignant  ovarian  disease. 


349 


CHAPTER  XIII. 

EXAMINATION  OF  THE  URINE  AND  THE  SIGNIFI- 
CANCE OF  URINARY  SYMPTOMS.' 

The  urine  is  usually  examined  to  some  extent  in  all  hos- 
pital cases  on  admission  as  a  niatter  of  routine.  The  nature 
of  any  further  examination  is  determined  by  the  character 
of  the  case.  In  private  practice,  the  examination  of  the 
urine  is  called  for  on  the  detection  of  any  suspicious  symptoms 
likely  to  be  associated  with  urinary  disturbances  ;  and  the 
beginner  will  do  well  to  examine  it  in  all  cases  where  the 
diagnosis  remains  doubtful.  Patients  also  frequently  com- 
plain of  changes  in  the  character  of  their  urine  ;  these  will  be 
referred  to  in  describing  the  naked  eye  appearances  (see  p. 
354). 

The  routine  examination  of  the  urine  embraces  a  note  of 
its  reaction,  its  specific  gravity,  its  color,  and  other  naked 

'  Regarding  the  examination  of  the  urine  the  works  of  Parkes 
and  of  Neubauer  and  Vogel  may  be  consulted.  The  editions  of  the 
latter,  subsequent  to  the  translation  issued  by  the  New  Sydenham 
Society,  may  be  referred  to  for  the  more  recent  views.  The  more 
obscure  points  in  the  chemistry  of  the  urine  are  dealt  with  very 
fully  by  Thudicum  in  his  recent  work,  and  the  various  quantita- 
tive methods  of  analysis  are  there  given.  Watts's  Dictionary  of 
Chemistry  contains  several  articles  of  great  value  for  reference  in 
this  connection.  Dr.  Beale's  works  are  also  constantly  referred  to, 
and  his  plates  of  urinary  deposits  are  of  special  value. 

Dr.  Wm.  Roberts  in  his  book  deals  with  the  examination  of  the 
urine  in  sutficient  detail  for  most  purposes,  and  he  goes  very  fully 
into  the  clinical  history  of  the  various  renal  and  urinary  affections. 
Dickinson's  work  on  Diseases  of  the  Kidney  and  Urinary  Derange- 
ments does  not  deal  with  the  examination  of  the  urine  in  detail, 
but  it  embraces  the  various  affections  of  these  organs  (Part  1,  Dia- 
betes ;  Part  2,  Albuminuria ;  Part  3,  Other  Affections  of  the  Kid- 
neys, &c.).  On  Bright's  Disease  the  works  of  Drs.  George  .Johnson 
and  Grrainger  Stewart  must  also  be  named  as  of  special  value. 

The  work  of  Dr.  Pavy  on  Diabetes  is  of  great  importance  ;  this 
disease  is  likewise  discussed  by  Roberts,  Dickinson,  and  Beale. 

Surgical  treatises  must  also  be  referred  to  regarding  diseases  of 
the  bladder  and  certain  affections  on  the  border  line  between  medi- 
cine and  surgery.  See,  for  example,  Holmes's  "System,"  Vol.  IV. 
30 


350  URINE    AND    URINARY    SYMPTOMS. 

eye  appearances ;  also  a  note  of  the  presence  or  absence  of 
albumen,  and  of  the  character  of  any  sediment,  microscopi- 
cally and  otherwise.  Tliese  points  should  be  noted  in  all 
hospital  cases  on  admission,  even  if  the  results  seem  purely 
negative  in  their  indications,  as  they  may  be  of  much  value 
in  the  subsequent  development  of  the  case.  The  nature  of 
the  further  investigations  depends  to  some  extent  on  the  re- 
sults of  this  examination.  Thus,  if  the  specific  gravity  be 
high,  especially  in  a  pale  urine,  sugar  must  be  tested  for  and 
the  quantity  of  urine  ascertained.  If  the  specfic  gravity  be 
low  and  the  color  pale,  the  quantity  passed  in  the  twenty- 
four  hours  will  be  important.  In  cases  with  albuminuria 
some  notion  of  the  quantity  of  the  urine  is  usually  desirable 
to  guide  not  only  the  diagnosis,  but  also  the  prognosis  and 
treatment ;  sometimes  exact  measurements  of  the  quantity 
of  the  urine  are  of  the  utmost  value.  Special  circumstances 
in  the  case  determine  the  further  investigations.  Thus  the 
propriety  of  an  estimation  of  an  abundance  of  the  chlorides 
in  febrile  cases,  of  the  urea  in  various  diseases,  of  the  biliary 
and  other  pigmentary  matters,  &c.,  must  be  determined  by 
the  general  clinical  features  of  the  case. 

The  samples  to  he  selected  for  testing  depend  to  some  extent 
on  the  points  specially  aimed  at  in  the  inquiry.  For  the 
reaction,  the  sample  should  be  quite  fresh,  and  if  alkaline  the 
relation  of  the  specimen  to  meal  times  must  be  considered. 
For  the  specific  gravity  the  whole  quantity  passed  in  the 
twenty-four  hours  should  be  tested,  or  a  sample  taken  from 
it.  In  examining  for  crystals  or  tube-casts,  the  sample  should 
be  allowed  to  settle  quietly  and  completely  for  several  hours. 
In  suspected  albuminuria  we  should  examine  samples  passed 
at  different  periods  of  the  day,  as  in  slight  cases,  the  albumen 
is  often  absent  in  the  urine  passed  before  breakfast,  and  ap- 
pears in  considerable  quantity  after  breakfast  or  dinner.  The 
urine  passed  in  the  early  morning  gives  the  fairest  samples 
of  the  secretion,  apart  from  the  influence  of  special  meals.  In 
private  practice  it  is  a  good  plan  to  procure  two  separate 
samples  passed,  the  one  in  the  morning,  and  the  other  at 
night.  In  hospital,  the  early  morning  samples  may  be  or- 
dered to  be  kept  in  the  first  instance,  and  the  whole  quantity 
or  special  samples  subsequently  ordered,  as  occasion  seems 
to  require.  Too  much  care  cannot  be  taken  in  securing  the 
cleanness  and  purity  of  the  samples,  both  as  to  the  vessels 
into  which  the  urine  is  originally  passed,  and  as  to  the  urine 
glasses   and    bottles   in    which  the    samples  are    preserved. 


QUANTITY    or    URINE.  351 

Dirty  vessels  promote  speedy  putrefoction,  and  give  rise,  very 
readily  to  ammoniacal  odor,  and  to  the  development  of  vibri- 
ones  in  urines  which  would  not  otherwise  present  these  fea- 
tures so  soon.  The  presence  of  syrups  and  the  like,  in  im- 
perfectly washed  bottles  used  for  the  samples,  may  give 
rise  to  serious  mistakes.  In  hospital  practice  another  danger 
arises  from  the  samples  being  contaminated  with  tube-casts 
and  crystals  from  the  urine  of  neighboring  patients,  who  may 
have  been  using  the  same  vessels. 

In  some  cases  of  purulent  and  bloody  urine,  especially,  it 
is  desirable  to  have  the  sample  passed  into  two  glasses,  so  as 
to  have  the  first  and  second  portions  separately,  as  such  an 
examination  brings  out  certain  peculiarities  in  various  forms 
of  urinary  disease. 

Quantity This  varies  in  health  according  to  the  size 

of  the  patient,  the  quantity  of  fluid  he  consumes,  and  the 
amount  of  his  excretions  by  the  skin,  bowels,  &c.  It  may 
be  roughly  estimated  at  from  30  to  50  or  60  fluid  oz.  in  the 
twenty-four  hours.  In  disease  the  modifying  influences  re- 
ferred to  have  also  some  play.  In  particular,  a  profuse  dis- 
charge from  the  bowels  or  skin  naturally  lessens  the  urine. 
The  quantity  of  the  urine  should  always  be  considered  in  its 
relationship  with  the  specific  gravity,  as  this  sometimes 
enables  us  to  understand  and  estimate  the  value  of  the 
changes  which  occur.  Thus  in  a  urine  diminished  by  diar- 
rhoea the  specific  gravity  may  rise  ;  in  a  urine  increased 
from  greater  quantities  of  fluid  being  imbibed  the  specific 
gravity  may  fall.  There  is  often  a  difficulty  in  preserving 
the  whole  urine  passed  by  a  patient,  partly  from  forgetful- 
ness  on  his  part,  especially  if  he  be  well  enough  to  go  about, 
and  partly  from  the  great  tendency  the  urine  has  to  be 
passed  at  stool  and  so  lost.  By  getting  the  patient  to  pass 
water  before  going  to  stool  this  loss  may  often  be  prevented, 
and  in  male  patients  a  wide-mouthed  bottle  can  easily  be 
used  simultaneously.  Sometimes,  however,  the  loss  is  in- 
evitable, both  from  this  cause  (as  in  diarrhoea),  and  from  the 
urine  dribbling  away,  or  from  its  being  passed  uncon- 
sciously and  without  warning. 

Suppression  of- urine,  or  even  any  great  diminution  of  its 
amount,  is  always  a  serious  symptom  and  fact  in  disease  ;  but 
the  report  is  sometimes  given  that  there  is  suppression  of 
urine  when  really  it  is  retained  in  the  bladder.  When  the 
quantity  of  the  urine  is  as  low  as  10  or  20  oz.  in  the  twenty- 
four  hours,  it  must  be  regarded  as  small ;  it  sometimes,  how- 


352  TJRINE    AND    URINARY    SYMPTOMS. 

ever,  falls  to  a  few  drachms  only  :  when  above  60  oz.  on 
several  successive  days  it  is  decidedly  increased.  It  is  well 
(owing  to  the  confusion  arising  from  various  measures  in  the 
country)  to  have  the  urine  measured  in  fluid  ounces,  or,  if 
the  quantities  be  large,  in  imperial  pints  (20  fluid  oz.). 
When  the  quantities  passed  are  moderate,  they  may  some- 
times be  preserved  with  advantage  for  our  inspection  in 
large  glasses  graduated  in  ounces,  and  in  this  way  the  speci- 
fic gravity  of  the  whole  can  be  readily  taken. 

Specific  Gravity This  is  usually  taken  by  means  of 

the  urinometer  which  is  introduced  into  the  sample,  in  a 
urine  glass,  and  the  level  of  the  fluid  on  the  stem  gives  the 
reading,  as  calculated  for  a  temperature  of  60°  F.,  pure 
water  being  1000.  The  level  of  the  general  surface  of  the 
urine  should  be  taken  and  not  that  of  the  drop  which  runs 
up  the  stem  :  it  should  be  seen  that  the  instrument  floats 
freely  and  keeps  clear  of  the  sides  and  the  bottom  of  the 
glass.  As  a  rule,  we  need  not  be  very  particular  as  to  the 
temperature  being  exactly  60°,  but  we  must  not  take  the 
specific  gravity  when  the  urine  is  newly  passed  and  so  much 
hotter  than  this  temperature.  The  stem  of  the  hydrometer 
should  be  long,  so  as  to  give  accurate  readings  more  easily, 
and  as  these  instruments  are  often  wrong  in  their  graduation 
some  test  of  their  accuracy  is  desirable,  by  comparing  them 
with  a  standard  or  by  the  vise  of  the  balance.  When  the 
quantity  is  too  small  to  allow  of  the  instrument  floating 
freely,  a  narrower  vessel,  or  some  means  of  displacing  the 
fluid,  may  enable  us  to  manage  our  purpose.  The  specific- 
gravity  bottle  is  of  course  available  in  the  case  of  the  sample 
being  very  small,  or  of  greater  accuracy  being  desired,  and 
specific  gravity  "  beads"  are  sometimes  employed.  In  test- 
ing a  series  of  urines,  the  hydrometer  should,  of  course,  be 
dried  to  prevent  contamination  of  one  specimen  by  another. 
As  already  stated,  the  specific  gravity  of  the  sample  noted 
should  be  that  of  the  twenty-four  hours'  quantity,  or,  if  not, 
allowance  must  be  made  for  a  possible  deviation  :  in  many 
cases  the  specific  gravity  of  samples  passed  at  difi^erent  hours 
varies  enormously.  The  specific  gravity  must,  as  already 
stated,  be  considered  in  relation  with  the  quantity  passed. 
High  specific  gravities  (above  1025)  are  found  in  diabetes 
(from  sugar)  ;  in  urines  with  a  concentration  of  the  normal 
ingredients  from  febrile  or  other  diseases,  or  from  a  limited 
consumption  of  fluid  ;  in  the  scanty  urine  of  acute  renal 
dropsy ;  and  in  rare  cases,  from  an  enormous  quantity  of 


THE    REACTION    OF    URINE.  353 

albumen  being  held  in  solution.  Low  specific  gravities 
(below  1015)  occur  in  nearly  all  cases  (except  diabetes  mel- 
litus)  where  the  quantity  is  large,  and  especially  in  diabetes 
insipidus  ;  in  cases  of  lardaceous  disease  of  the  kidney,  with 
a  large  secretion  of  urine  ;  and  in  general  in  all  chronic 
cases  of  Bright's  disease.  Temporary  depression  of  the 
specific  gravity  is  met  with  in  hysterical  affections,  associ- 
ated with  a  profuse  flow  of  urine,  and  also  in  the  gush  of 
water  escaping  from  a  hydronephrosis,  and  in  rare  cases, 
even  in  the  small  quantities  which  succeed  in  passing  the 
meclianical  impediment  if  both  ureters  be  obstructed:  the 
specific  gravity  differentiates  scanty  urine  in  such  cases  from 
that  passed  in  acute  nephritis,  as  in  this  last  affection  the 
specific  gravity  is  always  high  in  proportion  to  the  degree  of 
suppression. 

The  Reaction  of  Ubine  is  tested  with  blue  and  red  lit- 
mus paper.  Normally  it  is  acid ;  but  even  in  health  it  may, 
occasionally,  be  neutral  or  slightly  alkaline  at  certain  parts 
of  the  day,  and  especially  after  food  containing  many  alka- 
line salts.  The  acidity  may  be  unusually  great  (as  in 
lithiasis)  :  the  degree  can  be  determined  by  the  alkalimeter. 
In  cei'tain  depressed  states  of  the  general  health,  in  some 
cases  of  abundant  acid  vomiting,  in  some  forms  of  spinal 
paralysis,  and  in  long  standing  disease  of  the  bladder  with 
retention  or  incontinence,  the  urine  is  habitually  alkaline, 
and  the  reaction  has  thus  a  certain  value  in  diagnosis.  Nor- 
mal urine  often  becomes  more  acid  for  some  hours  after 
being  passed  (urinary  acid  fermentation)  ;  but  all  urines 
which  are  allowed  to  stand  long  enough  decompose  and  be- 
come alkaline,  from  the  conversion  of  the  urea  into  am- 
monia, so  that  we  must  see  to  have  the  samples  fresh. 
Alkalinity  from  ammonia  (volatile  alkali)  may  be  discrimi- 
nated from  that  due  to  soda  or  potash  (fixed  alkali),  by 
gently  heating  the  test-paper  which  has  been  turned  blue  by 
the  urine,  as  the  volatile  alkali  is  in  this  way  driven  off,  and 
the  red  color  returns.  Tlie  reaction  of  urine  is  of  value  in 
tlie  recognition  of  urinary  deposits  :  a  bulky  deposit  which 
forms  soon  after  the  urine  is  passed  may  usually  be  pro- 
nounced to  consist  of  uric  acid  or  its  salts  (urates),  if  the 
reaction  be  acid;  if,  on  the  other  hand,  such  a  deposit  con- 
curs with  an  alkaline  or  even  a  neutral  reaction,  the  proba- 
bility is  that  it  is  phosphatic  (the  addition  of  an  alkali  to 
normal  urine  precipitates  the  phosphates).  The  persistence 
of  pus  in  urine  of  acid  reaction  points  to  a  renal  origin  ;  pus 

80* 


354  URINE    AND    URINARY    SYMPTOMS. 

from  the  bladder,  if  persistent,  usually  renders  the  urine 
alkaline  and  ammoniacal.  Care  must  be  taken  to  have  the 
samples  fresh  in  such  cases,  as  urine  with  much  pus,  from 
any  cause,  rajiidly  decomposes.  Alkalinity  of  the  urine  is 
sometimes  a  point  aimed  at  in  treatment  by  the  administra- 
tion of  potash  or  other  alkaline  medicines  (rheumatism, 
lithiasis,  gout)  :  the  reaction  must  be  determined  by  fre- 
quent testing  in  such  cases,  as  the  urine  rendered  alkaline  by 
remedies  readily  becomes  acid  on  any  interruption  or  dimi- 
nution of  the  dose.  On  the  other  hand,  medicines  seem  to 
have  little  chemical  power  in  rendering  an  alkaline  urine 
acid.  Benzoic  and  carbonic  acid,  however,  seem  to  have 
some  influence  in  this  respect. 

The  obvious  characteristics  of  Urine  are  of  im- 
portance not  only  as  regards  the  samples  we  examine  our- 
selves, but  also  as  regards  the  description  or  alterations 
mentioned  by  patients.  Both  of  these  will  be  considered 
here.  Normal  urine  has  a  pale  yellow  tint,  is  clear  Avhen 
passed,  but  deposits,  on  standing,  a  faint  cloud  of  mucus, 
which  forms  only  a  slight  sediment.  This  mucus  is  some- 
times more  abundant  than  natui-al,as  in  slight  catarrh  of  the 
bladder,  and  this  excess  may  pass  gradually  into  a  deposit 
of  muco-pus.  When  the  cloud  is  absent,  this  usually  im- 
plies some  excess  in  the  quantity  of  the  urine,  which  has 
thus  w^ashed  away  or  diluted  the  mucus. 

The  color  and  clearness  of  urine  vary  much.  Tables  of 
colors  have  been  devised  by  Vogel  to  assist  the  naming  of 
the  variations :  he  makes  nine  gradations ;  pale  yellow, 
bright  yellow,  yellow;  reddish-yellow,  yellowish-red,  red; 
brownish-red,  reddish-brown,  brownish-black.  If  the  urine 
be  turbid,  it  should  be  ascertained,  if  possible,  if  it  were  so 
when  passed,  or  if  it  only  became  so  afterwards.  Turbidity, 
when  freshly  passed,  may  depend  on  decomposition  going  on 
within  the  bladder,  or  an  excess  of  vesical  mucus,  or  on  the 
presence  of  renal  epithelium  and  shreds,  pus,  blood,  semen 
and  prostatic  secretions,  bile,  uric  acid,  urate  of  soda  (hedge- 
hog crystals),  phosphates,  chyle  or  sarciniB.  When  the 
urine  is  clear  on  being  passed  and  afterwards  becomes  tur- 
bid, tliis  is  usually  due  to  the  precipitation  of  urates  or  of 
phosphates,  or  to  decomposition,  or  saccharine  fermentation. 
When  the  sediment  has  completely  fallen,  sometimes  the 
supernatant  fluid  is  perfectly  clear;  sometimes  it  remains 
slightly  turbid  from  some  remaining  admixture  of  the  sedi- 
mentary matter. 


OBVIOUS    CHARACTEEISTICS    OF    URINE.         355 

Patients  frequentl}^  complain  of  the  urine  being~^z^^- 
colored  and  scanty :  this  often  arises  from  simple  concentra- 
tion of  the  secretion  in  febrile  diseases,  apart  from  any 
special  renal  affection,  but  it  also  occurs  in  acute  nephritis. 
Urine  white  like  milk  is  often  spoken  of  in  the  case  of  chil- 
dren, and  this  character  is  usually  due  to  the  presence  df 
white  urates  or  colorless  uric  acid  crystals.  In  adults,  if  the 
urine  be  milky  when  passed,  this  is  usually  due  in  them  to 
the  presence  of  earthy  phosphates  (arising,  perhaps,  from  a 
transient  alkalinity  of  the  urine  after  dinner)  :  unless  persist- 
ent this  is  usually  of  no  real  importance :  or  the  turbidity 
may  be  due  to  the  presence  of  pus,  which  is  always  of  more 
or  less  serious  significance  ;  in  rare  cases  it  may  be  due  to 
x;hyle,  to  spermatic  fluid  or  sarcinse.  When  the  patient  de- 
scribes the  urine  as  "  turning  thick  "  this  is  almost  always 
due  to  a  deposit  of  urates  on  the  cooling  of  the  urine,  and  is 
seldom  of  much  consequence.  When  spoken  of  as  '■'■  re- 
sembling porter"  the  presence  of  bile  in  some  quantity  is 
usually  indicated,  but  blood  may  also  give  such  a  color. 
When  described  as  tiirhid  and  smoky  when  passed,  this  may 
be  due  to  a  slight  and  intimate  admixture  with  blood,  and 
hlood  color  in  a  more  pronounced  form,  depends  on  a  greater 
quantity  of  florid  blood  being  passed ;  clots  may  also  come 
away  either  of  a  florid  color  or  of  a  darker  hue,  or  even  of  a 
chocolate  appearance.  Very  red  urine,  having  something  of 
the  bloody  tint,  is  sometimes  due  to  excessively  red  urates, 
especially  as  found  in  certain  hepatic  cases.  Very  pale 
urine  is  found  usually  when  the  quantity  is  habitually  exces- 
sive, as  in  diabetes,  and  in  certain  forms  of  chronic  disease 
of  the  kidney ;  or  it  may  also  concur  with  a  temporary  in- 
crease in  the  quantity,  from  free  imbibition  of  fluids,  or  in 
connection  with  hysterical  or  nervous  attacks  in  both  sexes. 
Anaemia  may  also  be  responsible  for  the  paleness  of  the  urine. 
Black  urine  is  sometimes  passed  by  those  using  carbolic  acid 
or  creasote,  either  externally  or  internally  ;  more  frequently 
this  black  color  only  appears  after  the  urine  has  been  kept 
lor  a  time  ;  the  addition  of  a  minute  quantity  of  strong  vit- 
riol (unjmrified)  frequently  brings  out  a  greenish  color  in 
such  cases,  but  this  test  is  rather  uncertain.  A  dark  red  or 
almost  black  color  is  sometimes  formed  in  the  urine  in  cases 
of  melanosis.  Indigo  blue  has  occasionally  been  found  in 
urine  ai'ter  it  has  been  standing  for  a  time  and  has  become 
alkaline.  Bad  odor  in  the  urine  when  passed  depends,  as  a 
rule,  on  decomposition  occurring  within   the   bladder,  or  on 


356  URINE    AND    URINARY    SYMPTOxMS. 

the  escape  of  an  abscess  into  it,  and  is  significant  of  cystitis, 
&c.  Certain  vegetables  impart  a  strong  odor  to  the  urine, 
and  the  smell  of  many  articles  used  in  the  food  or  drink  may 
be  recognized  in  the  urine.  In  oxaluria  a  certain  resem- 
blance to  the  odor  of  sweet-bri(!r  may  sometimes  be  recog- 
nized, and  during  the  administration  of  turpentine  there  is 
sometimes  a  smell  as  if  from  sweet  violets,  but  these  cannot 
be  said  to  be  unpleasant.  Gas  coming  with  the  urine  sug- 
gests some  communication  of  the  urinary  passage  with  the 
bowels.  Shreds  and  fibrous  masses  may  be  passed  in  cases 
of  chronic  inflammation  of  the  bladder,  or  they  may  come 
from  an  inflamed  and  dilated  kidney  (Pyelo-nephritis). 
Gritty  matter  or  gravel  may  also  be  complained  of  as  coming 
Avith  urine  and  irritating  the  urethra :  this  will  usually  be 
found  on  examination  to  be  due  to  uric  acid,  or,  more  rarely, 
to  other  forms  of  calculous  concretions.  Urinary  sediments 
usually  demand  chemical  tests  or  microscopic  examination 
for  their  discrimination  (see  p.  380).  Sometimes  crystals 
of  uric  acid  can  be  seen  by  the  naked  eye,  or  with  a  simple 
lens,  resembling  cayenne  pepper  grains,  falling  to  the  bottom 
of  the  glass,  or  adhering  to  its  sides,  or  to  shreds  of  mucus. 
Glittering,  colorless  prisms  of  ammonio-magnesian  phosphate 
can  also  sometimes  be  thus  seen  floating  as  a  scum  on  the 
surface  of  the  urine,  or  resting  on  the  mucous  sediment,  or 
adhering  to  the  sides  of'  the  glass.  A  very  delicate  and 
minute  powdery  sediment  covering  the  top  of  the  cloud  of 
mucus,  and  resembling,  as  has  been  said,  fine  powder  dusted 
over  a  wig  ("powdered  wig  deposit"),  can  sometimes  be 
recoo-nized  with  tolerable  certainty  as  due  to  oxalate  of  lime 
crystals ;  occasionally,  in  alkaline  urines,  minute  phosphatic 
crystals  simulate  this  appearance ;  as  a  rule,  however,  the 
latter  are  more  glittering  than  the  former.  Fawn-colored, 
pink  or  reddish  amorphous  precipitates,  formed  as  the  urine 
cools,  can  usually  be  recognized  at  once  by  the  naked  eye  as 
composed  of  urates  (urate  of  ammonia,  potash,  and  soda)  : 
when  the  deposit  is  whitish,  there  is  more  difficulty;  white 
urates,  or  even  uric  acid,  earthy  phosphates,  and  pus,  may 
be  scarcely  distinguishable  from  each  other  by  the  naked 
eye.  A  glairy  whitish  or  yellowish  material^  floating  on 
the  surface  of  the  urine,  or  diffused  through  it,  is  often  seen 
when  the  sample  is  contaminated  with  leucorrhoeal  discharges. 
Urine  with  a  whitish  turbidity  forming  a  coagulum  on 
standing  is  mixed  with  chyle. 


COPPER  TEST  FOR  SUGAR.  351 


SUGAR  IN  URINE. 

Sugar  should  be  tested  for  in  any  complete  examination 
of  the  urine,  and  especially  in  all  cases  in  which,  from  the 
symptoms,  diabetes  is  suspected ;  or  when  either  the  quan- 
tity of  urine  is  excessive,  or  the  specific  gravity  is  unusually 
high  (above  1030).  It  should  also  be  remembered  that  in 
certain  cases  of  cerebral  disease,  with  or  without  distinct 
paralysis,  and  particularly  in  some  cases  of  cerebral  tumor, 
sugar  appears  in  the  urine.  When  examining  for  sugar, 
albumen  should  also  be  tested  for,  not  only  because  its  pres- 
ence is  a  serious  complication  in  diabetes,  but  also  because 
the  presence  of  albumen  may  interfere  with  the  certainty  of 
the  reactions  for  sugar  by  the  copper  test ;  in  such  cases  the 
albumen  should  be  precipitated  by  heating,  with  the  addi- 
tion of  a  little  acid,  and  subsequent  filtration.  Boiling  the 
albuminous  urine  with  crystals  of  sulphate  of  soda  is  likewise 
said  to  yield  a  fluid  suitable  for  the  application  of  the  copper 
test. 

Copper  Test — Trommer's  Test This  is  based  on  the 

power  which  diabetic  sugar  has  of  reducing  copper  salts 
under  certain  conditions.  A  few  drops  of  a  solution  of  sul- 
phate of  copper  are  mixed  with  a  little  urine  in  a  test  tube, 
excess  of  liquor  potasste  is  then  cautiously  added,  just 
enough  to  dissolve  the  precipitate  which  it  throws  down  in 
the  first  instance ;  the  mixture  is  boiled,  and  if  sugar  be 
present,  a  red  precipitate  of  the  sub-oxide  falls  down. 
Errors  are  frequently  made  in  applying  this  test  from  not 
using  the  proper  relative  proportions  of  copper  and  potash 
with  the  urine. 

Fehling's  Test  Solution^  (or  Pavy's)  obviates  some  of  these 
difficulties.     A  portion  of  the  test  fluid  is  first  boiled  in  a 

'  Fehling's  Solution. — Sulphate  of  Copper,  90^  grains ;  Neutral 
Tartrate  of  Potash,  364  grains  ;  Solution  of  Caustic  Soda  (of  sp.  gr. 
1.12)  4  fluidounces.  Add  water  to  make  up  exactly  to  6  fluidounces. 
(Or  40  grammes  of  sulphate  of  copper  in  crystals ;  160  grammes 
neutral  tartrate  of  potash;  750  grammes  caustic  soda,  sp.  gr.  1.12; 
add  water  up  to  1154.5  cubic  centimetres.  Each  10  c.  c.  correspond 
to  0.05  gramme  of  grape  sugar.) 

Pavy's  Solution.— Sul-phate  of  Copper,  320  grains ;  Tartrate  of 
Potash  (neutral),  640  grains;  Caustic  Potash  (potassa  fusa),  1280 
grains  ;  Distilled  Water,  20  fluidounces. 

The  tartrate  of  potash  and  caustic  potash  are  dissolved  together 
in  one-half  of  the  water,  the  sulphate  of  copper  in  the  other  half ; 
the  two  solutions  are  then  mixed. 


358  URINE    AND    URINARY    SYMPTOMS. 

test-tube  to  see  if  it  remains  unchanged  in  color  (as  it  is  apt 
to  become  altered  by  keeping)  ;  if  unaffected,  a  drop  or  two 
of  the  suspected  urine  is  added  ;  if  sugar  be  present  in  any 
quantity,  the  color  at  once  changes,  and  a  yellowish  or  red- 
dish precipitate  comes  down.  If  this  does  not  happen,  a 
little  more  urine  should  be  added  (but  always  so  as  to  be  less 
than  the  volume  of  the  test  fluid  in  the  tube),  and  the  whole 
should  again  be  boiled  and  allowed  to  cool ;  if  no  yellow  or 
red  suboxide  comes  down  it  may  be  pronounced  free  of  sugar. 
Cautions. — Prolonged  boiling  must  be  avoided,  as  reduc- 
tion may  occur  in  this  way  apart  from  sugar.  Boiling  the 
urine  before  adding  the  test  fluid,  is  also  apt  to  lead  to  error. 
Adding  too  much  urine  is  also  to  be  avoided,  as  a  great  ex- 
cess of  non-saccharine  urine  may  reduce  the  copper.  The 
test  fluid  must  be  in  good  condition — capable  of  resisting 
boiling  without  being  changed ;  in  delicate  inquiries,  it  is 
desirable  to  add  an  equal  bulk,  or  more,  of  pure  water  to  the 
boiling  test  fluid,  to  boil  again,  and  to  allow  the  whole  to 
cool  slowly  so  as  to  have  complete  security  of  the  perfect 
condition  of  the  copper  solution. 

The  Quantity  of  Sugar  maij  also  he  determined  hy  the  copper  test. 
Feliling's  or  Pavys  Solutions  are  made  of  such  strength  that  200 
grains  (by  measure)  are  completely  reduced  by  one  grain  of  diabetic 
sugar.  The  test  fluid  is  boiled  in  a  porcelain  capsule  or  a  glass 
flask  (a  piece  of  caustic  potash,  the  size  of  a  pea,  being  added  in 
the  case  of  Pavy's  solution)  and  a  quantity  of  pure  water,  equal  to 
one  or  two  volumes  of  the  test  fluid,  is  poured  in  also.  The  sac- 
charine urine  should  then  be  dilated  with  pure  water,  in  the  pro- 
portion of  1  volume  of  urine  to  9  of  water,  if  the  sugar  is  abundant ; 
or  in  a  less  proportion  (or  without  dilution)  if  the  sugar  is  scanty. 
The  diluted  urine  is  introduced  into  a  burette,  graduated  to  grains, 
and  is  then  gradually  added  to  the  boiling  copper  solution  till  the 
blue  color  is  quite  discharged.  lu  order  to  judge  of  this  a  minute 
or  two  must  be  allowed  for  the  red  precipitate  to  fall,  otherwise  it 
obscures  the  blueness  which  may  remain  in  the  supernatant  fluid. 
When  the  precipitate  falls,  by  holding  up  the  flask  to  daylight,  or 
against  a  white  object,  or  by  looking  down  through  the  fluid  to  the 
white  sides  of  the  porcelain  dish,  if  this  be  used,  any  remnant  of 
blue  color  is  readily  detected.  If  this  can  be  recognized  the  mix- 
ture is  again  brought  to  the  boiling  point,  and  a  few  drops  of  the 
diluted  urine  are  again  added.  Too  much  time  must  not  be  al- 
lowed to  elapse  in  waiting  for  the  red  precipitate  to  fall,  as  after 
standing  for  a  length  of  time  the  suboxide  is  redissolved,  and  the 
blue  color  is  reproduced.  The  number  of  grains  of  urine  con- 
sumed in  the  experiment  is  then  read  ofi",  and  this  represents  the 
quantity  which  contains  one  grain  of  sugar ;  it  is  then  a  matter  of 
calculatiim  how  many  grains  of  sugar  are  contained  in  the  ounce 
of  urine  (437j  grs.  in  an  ounce  avoirdupois).    Allowance,  of  course, 


FERMENTATION    TEST.  S59 

is  made  in  the  calculation  for  the  degree  of  dilution  employed.  If 
the  total  quantity  of  urine  passed  in  the  day  be  known,  the  total 
quantity  of  sugar  excreted  can  then  be  readily  calculated. 

Fermentation  Test — Occasionally,  from  uncertainties 
in  the  results  of  the  copper  test  from  various  causes,  it  is 
important  to  decide  as  to  the  presence  of  sugar  by  fermenta- 
tion ;  sugar  is  the  only  substance  known  which  ferments 
with  yeast  and  liberates  carbonic  acid  gas.  A  small  tube 
may  be  nearly  filled  wnth  the  suspected  urine,  a  little  fluid 
or  solid  (German)  yeast  is  then  added,  and  the  whole  filled 
up  with  metallic  mercury,  and  inverted  over  a  little  of  the 
same  metal  in  a  cup  ;  the  apparatus  is  then  put  in  a  warm 
place  and  allowed  some  time  to  ferment.  If  sugar  be  present, 
in  other  than  very  minute  quantity,  gas  accumulates  in  the 
tube,  and  this  can  be  shown  to  be  carbonic  acid  by  testing 
with  lime-water.  It  is  w^ell  to  conduct  a  blank  experiment 
with  simple  water  and  the  yeast  at  the  same  time,  as  a  secu- 
rity against  the  gas  being  formed  in  any  other  way. 

Torula   test The  detection  of  torulae   (see  Fig.  o5,  p. 

380),  occasionally  assists  in  the  diagnosis  of  saccharine 
urine,  or  directs  attention  to  its  examination  by  chemical 
reagents. 

The  Quantitative  Text  hy  fermentation,  as  described  by  Dr.  Roberts, 
of  Manchester,  consists  in  determining  the  specific  gravity  of  the 
urine  before  and  after  complete  fermentation.  A  small  lump  of 
German  yeast  (the  size  of  a  walnut)  is  added  to  four  ounces  of 
urine,  the  specific  gravity  of  which  has  first  been  carefully  taken 
and  noted;  this  is  placed  in  a  large  wide  bottle  (12  oz.),  corked, 
but  with  an  opening  cut  in  the  cork  so  as  to  allow  the  carbonic  acid 
to  escape  ;  it  is  then  placed  in  a  moderately  warm  situation,  and  in 
the  course  of  24  hours,  or  when  the  fermentation  is  completed,  it  is 
allowed  to  cool,  and  its  specific  gravity  is  again  taken  at  the  same 
temperature  as  before  the  fermentation  was  begun.  The  loss  in  the 
specific  gravity  indicates  the  quantity  of  sugar  fermented  out.  The 
specific  gravity  is  reduced  partly  by  the  loss  of  the  sugar  formerly 
held  in  solution,  and  partly,  perhaps,  by  some  of  the  light  alcohol 
thus  generated  remaining  in  the  mixture.  To  avoid  any  fallacy 
from  a  ditference  in  the  temperature  of  the  fluid  at  the  two  separate 
observations  on  the  specific  gravity,  it  is  desirable  to  have  a  dupli- 
cate sample  of  the  original  urine,  without  yeast,  in  a  4  oz.  bottle, 
firmly  corked,  and  kept  beside  the  other  throughout,  so  as  to  com- 
pare the  specific  gravity  of  the  two  specimens  after  the  fermentation 
is  over.  It  has  been  found,  empirically,  that  one  degree  of  specific 
gravity  lost  by  fermentation,  corresponds  with  one  grain  of  sugar 
per  fluid  ounce  of  urine. 

ESTIMATIOX  OF  THE  QUANTITY  OF  SUGAR  FROM    THE  SPECIFIC  GRAVITY 

of  the  urine  is,  at  best,  a  rough  method,  as  complications  arise  from 


360  URINE    AND    URINARY    SYjMPTOMS. 

the  presence,  in  varying  proportions,  of  the  normal  solid  ingredi- 
ents of  the  urine.  This  source  of  difficulty  is  relatively  greater 
when  the  total  quantity  of  the  saccharine  urine  passed  daily  is  not 
excessive.  A  specific  gravity  which  is  not  excessive  cannot,  of 
course,  coincide  with  a  high  proportion  of  sugar  per  ounce.  A  high 
specific  gravity  with  a  very  large  quantity  of  urine  (several  quarts) 
may  be  safely  taken  as  evidence  of  a  high  proportion  of  sugar  in 
diabetes.  By  doubling  the  two  last  figures  in  the  reading  of  the 
sp.  gr.  we  obtain  a  rough  estimate  of  the  number  of  grains  oi  solids 
per  1,000  of  urine.     (Trapp.) 

Moore's  Test  for  Sugar  with  Liquor  Potass^  is  a 
favorite  method,  on  account  of  its  easy  application.  An 
equal  volume  of  urine  and  liquor  potassse  are  boiled  together, 
when  a  dark-brown  color  I'esults  in  cases  of  diabetes.  This 
is  not  a  test  suitable  for  small  quantities  of  sugar,  and  it  is 
subject  to  fallacies,  especially  from  the  presence  of  lead  in 
the  reagent,  as  this  may  arise  from  the  bottles  used.  This 
test  is  often  of  use  in  confirming  our  opinions  in  the  absence 
of  more  reliable  appliances. 

Bismuth  Test  for  Sugar.  A  solution  of  carbonate  of 
soda  is  prepared  in  the  proportion  of  one  part  of  the  crystals 
to  three  parts  of  water.  This  solution  is  mixed  with  a  little 
of  the  suspected  urine  in  equal  volumes,  and  a  pinch  of  the 
basic  nitrate  of  bismuth  is  then  added,  and  the  whole  boiled; 
if  sugar  be  present  the  bismuth  becomes  grayish  or  blackish 
from  the  formation  of  the  suboxide  or  of  metallic  bismuth. 
This  test  is  a  delicate  one,  but  is  not  available  for  quantita- 
tive analysis.  (In  the  absence  of  the  basic  nitrate  the  ordi- 
nary subnitrate  of  bismuth  may  be  employed.) 

The  Polariscope  is  available  both  for  the  qualitative 
and  quantitative  analysis  of  sugar,  provided  the  fluid  be 
decolorized  and  freed  from  any  other  ingredients  (such  as 
albumen)  which  act  on  polarized  light ;  but  the  instruments 
as  yet  are  rather  troublesome  and  expensive,  at  least  in  their 
accurate  forms. 

ALBUMINURIA. 

The  tests  for  albumen  relied  on  in  clinical  medicine  are 
two,  and  they  should,  as  a  rule,  both  be  applied,  at  least  in 
all  doubtful  cases.  They  are  (1)  Boiling,  with  the  subse- 
quent addition  of  a  drop  or  two  of  acetic  or  nitric  acid ;  and 
(2)  The  application  of  strong  nitric  acid  to  the  cold  urine. 
Various  other  agents  precipitate  albumen,  and  are  used  for 
special  inquiries  —  Corrosive  Sublimate,  Ferrocyanide  of 
Potassium,   Alcohol,    Ether,    Chloroform,    Chromic    Acid, 


TESTS    FOR    ALBUMEN.  361 

Picric  Acid,  Carbolic  Acid,  &c.  Some  of  these  liave^been 
introduced  into  clinical  medicine,  and  may  perhaps  be  used 
occasionally  with  advantage;  but  the  clinical  significance  of 
the  precipitates  obtained  from  some  of  them  remains  still  so 
doubtful  that  we  fall  back  with  the  more  confidence  on  the 
two  methods  named  above,  which  have  stood  the  test  of  long 
experience.  It  should  be  seen  to  that  suitable  samples  are 
examined  before  pronouncing  the  absence  of  albuminuria. 
(See  p.  350.) 

1.  Test  hy  heat.  The  urine,  clear  (if  possible),  is  heated 
in  a  test-tube  to  the  boiling  point,  and  a  drop  or  two  of 
strong  acetic  or  of  nitric  acid  are  then  added.  If  albumen 
be  present  there  is  a  turbidity,  or  a  precipitate,  which  does 
not  dissolve  on  adding  the  acid.  If  the  amount  of  albumen 
be  small,  by  heating  the  upper  half  of  the  fluid  in  the  test- 
tube  we  sometimes  can  demonstrate  the  reaction  more 
clearly.  If  the- urine  be  turbid  from  urates,  these  dissolve 
on  a  slight  application  of  heat  to  the  whole  quantity  in  the 
tube  (say  98°  F.).  The  test  is  not  interfered  with  by  this. 
If  the  turbidity  of  the  urine  cannot  thus  be  got  rid  of,  filter- 
ing may  be  resorted  to.  Occasionally  a  degree  of  tui'bidity 
remains  which  interferes  with  the  delicacy  of  this  test  for 
minute  quantities  of  albumen. 

Apart  from  this,  which  is  only  a  slight  imperfection,  some 
fallacies  in  the  heat  test  may  mislead  the  student,  (a.)  Al- 
bumen may  be  present,  but,  being  held  in  solution  by  alka- 
lies, it  may  not  come  down  on  heating.  Hence  the  pi'opriety 
of  trying  the  reaction  before  boiling,  and  the  necessity  of 
adding  acid  after  boiling,  before  deciding  on  the  result,  (h.) 
A  precipitate  may  form  on  heating,  somewhat  resembling 
albumen,  but  really  consisting  of  earthy  phosphates  ;  such  a 
precipitate  is  soluble  on  adding  a  little  acid,  a  precaution 
which  should  never  be  neglected  in  applying  this  test,  (c.) 
If  too  much  acid  be  added  to  the  boiling  urine  in  testing  the 
precipitate  which  forms,  this  may  dissolve  even  albumen ; 
excess  need  not  be  risked,  as  the  smallest  quantity  suffices 
to  dissolve  earthy  phosphates,  (d.)  Occasionally  a  minute 
trace  of  nitric  acid  in  the  test-tube  with  the  sample  of  urine 
(remaining  perhaps  in  badly  washed  test-tubes),  prevents 
the  precipitation  of  albumen  on  boiling.  Sometimes  the 
addition  of  even  a  little  acetic  acid  to  the  urine  before  boil- 
ing likewise  prevents  the  precipitation  of  albumen  by  heat, 
and  so  this  siiould  be  avoided  ;  even  a  great  natural  acidity 
of  the  urine  itself  has  been  known  to  prevent  the  precipita- 
■  31 


362  URINE    AND    URINARY    SYMPTOMS. 

tion  of  albumen  by  heat.  The  reaction  of  the  urine  for  the 
correct  application  of  this  test  should  be  just  slightly  acid. 
Any  acids  used  to  secure  this  must  be  applied  with  caution ; 
in  rare  cases  alkalies  must  be  used  to  neutralize  undue 
acidity. 

2.  Nitric  acid  added  to  the  cold  urine  forms  a  test  for  al- 
bumen of  gi'eat  value.  The  delicacy  of  this  test  in  pale 
urines  of  low  specific  gravity  is  quite  marvellous.  The 
strong  nitric  acid  may  be  added  to  a  small  quantity  of  urine 
in  a  test-tube,  ten  or  twelve  drops  of  the  acid  being  allow(;d 
to  trickle  down  the  side  of  the  tube ;  the  test-tube  should  be 
held  obliquely,  so  as  to  avoid,  if  possible,  the  commingling 
of  the  fluids.  The  acid  falls  to  the  bottom,  and  can  usually 
be  recognized  from  its  different  color,  or  (on  shaking  it  A'ery 
gently)  from  its  obviously  different  specific  gravity.  Another 
way  is  to  introduce  the  nitric  acid  first,  the  lighter  urine 
being  then  poured  down  very  slowly  and  cautiously,  so  as  to 
float,  without  mixing  much  with  the  acid.  With  either 
method  albumen,  if  present  in  the  urine,  forms  a  cloud  just 
above  the  level  of  the  acid  ;  or  if  the  quantity  be  minute,  a 
ring  of  haziness  appears  at  the  junction  of  the  two  fluids. 
A  third  way  of  applying  this  test  is  to  introduce  a  little 
nitric  acid  by  a  pipette  (the  outside  of  the  pipette  being 
wiped  free  from  acid)  right  down  to  the  bottom  of  the  urine 
in  the  test-tube.  All  these  methods  aim  at  getting  the  action 
of  the  acid  localized  to  a  part  of  the  urine  without  being 
diffused  through  it.  (A  ring  of  red  color  merely,  without 
turbidity,  at  the  junction  of  the  fluids  does  not  indicate  al- 
bumen. This  is  sometimes  very  marked,  and,  when  highly 
developed  on  boiling  the  acid  and  urine  together,  constitutes 
the  "  Urohajmatine"  supposed  by  Dr.  Harley  to  be  due  to 
the  loss  of  blood,  as  it  were,  in  a  disguised  form.) 

Certain  fallacies  and  difficulties  beset  the  nitric  acid  test 
also : — (o.)  If  the  quantity  of  albumen  be  minute,  some 
time  occasionally  elapses  before  the  haziness  is  developed. 
The  tube  should  be  left  at  rest  for  a  few  minutes  before  pro- 
nouncing that  there  is  no  haze  of  albumen,  (h.)  Occasion- 
ally, on  adding  nitric  acid  to  the  cold  urine,  a  more  or  less 
dense  precipitate  occurs,  not  from  albumen,  but  from  urates. 
This  usually  appears  first  near  the  surface  of  the  urine,  and 
not  at  its  junction  with  the  acid,  although  it  often  extends 
that  length.  A  very  gentle  heat  suffices  to  dissolve  this 
precipitate  of  urates ;  this  may  be  done  by  immersing  the 
tube  in  warm  water:  in  applying  heat  for  this  purpose  we 


NITRIC    ACID    TEST    FOR    ALBUMEN.  363 

must  avoid  anything  like  a  boiling  temperature,  as  albumen 
itself  dissolves  if  boiled  with  excess  of  nitric  acid  in  the  tube. 
A  further  confirmation  of  such  a  precipitate  being  due  to 
urates  may  often  be  obtained  by  getting  a  similar  reaction 
on  adding  a  drop  or  two  of  acetic  acid,  as  this  does  not  pre- 
cipitate albumen  in  cold  urine.  (Occasionally,  indeed,  an 
albuminous  principle  resembling  caseine  is  thus  precipitated 
by  acetic  acid.)  The  microscope  may  sometimes  also  assist 
us.  The  precipitate  of  amorphous  urates  maybe  recognized 
as  such  by  the  microscope ;  sometimes  crystals  of  uric  acid 
are  quickly  formed,  (c.)  When  the  urine  is  turbid,  the 
delicacy  of  this  test  is  lost.  Filtering  no  doubt  may  assist 
us  in  such  a  case,  but  besides  being  troublesome  it  is  apt  to 
be  imperfect  in  its  effect.  Wiien  the  turbidity  is  due  to 
urates  (the  commonest  cause),  by  heating  very  gently,  a 
clear  fluid  can  be  obtained  on  which  to  operate,  and  by 
keeping  the  tube  slightly  warm  (in  warm  water  or  in  the 
warm  hand),  this  clearness  may  be  maintained  long  enough 
for  the  satisfactory  application  of  the  test,  {d.)  A  precipi- 
tate formed  at  the  bottom  of  the  acid  consisting  of  nitrate  of 
urea  seldom  presents  any  difficulty  in  distinguishing  it  from 
albumen ;  it  is  crystalline,  readily  soluble  at  a  very  gentle 
heat,  and  usually  it  takes  a  long  time  to  form,  although  it 
sometimes  appears  in  a  few  minutes  when  the  urine  is  loaded 
with  urea. 

The  quanfitij  of  albumen  may  be  roughly  estimated  by  judging  of 
the  extent  of  tlie  precipitate  formed  on  boiling,  especially  after  it 
has  been  allowed  to  subside  in  the  tube  for  a  definite  time  (say 
twenty-four  liours)  :  its  amount  may  be  thus  estimated  at  a  lialf, 
a  fourth,  an  eighth,  &c.  Sometimes  the  quantity  is  indicated  by 
saying  a  "trace"  of  albumen,  or  "slight,"  or  "moderate,"  or 
"  lai'ge"  amounts,  as  the  case  may  be  ;  or  that  the  urine  is  solidi- 
fied on  heating.  Such  indications  are  of  clinical  importance,  but 
the  estimate  thus  made  has  little  chemical  value.  The  estimation 
by  i^reciintation  and  weighing  is  so  troublesome  as  to  be  practically 
unavailable  in  clinical  medicine. 

The  quuntitaiive  determination  of  albumen  by  nitric  acid,  as  proposed 
by  Dr.  William  Roberts,  is  based  on  the  fact  that  the  reaction  with 
this  test  takes  longer  to  show  itself  in  proportion  as  the  albuminous 
solution  is  dilute.  ludeed,  in  very  slight  degrees  of  albuminuria 
several  minutes  are  required  to  bring  out  the  haze  with  nitric  acid. 
The  test  consists  in  diluting  an  albuminous  urine  to  such  an  extent 
that  the  haze  becomes  perceptitile  in  a  definite  time,  when  a  definite 
quantity  of  urine  is  treated  with  a  definite  quantity  of  nitric  acid, 
in  a  tube  of  a  definite  width.  The  quantity  used  is  5  cubic  centi- 
metres of  the  fiuid  in  a  test  tube  fth  of  an  inch  (15  mm.)  in  its  in- 
ternal diameter :  the  nitric  acid  is  applied  by  a  pipette  drawn  to  a 


364  URINE    AND    TJRTNART    SYMPTOMS. 

point,  holding  10  or  12  minims  Mlien  immersed  to  tlie  depth  of  2 
imhes :  the  acid  is  disdiarged  against  the  side  of  the  tube  while  it 
is  held  at  an  angle  so  as  to  prevent  any  mixing  of  the  fluids:  the 
dilution  aimed  at  is  suc-h  as  to  give  rise  to  a  haze  appearing  not 
sooner  than  35  seconds  and  not  later  than  45  seconds.  The  tube 
must  be  held  uf)  to  the  daylight  and  watched  carefully  with  some 
Hack  object,  such  as  a  coat  sleeve,  in  the  vicinity.  If  tlie  reaction 
appears  before  30  sec-onds,  more  dilution  is  required;  if  not  till 
after  45  seconds,  less  dilution  must  be  employed.  A  drachm  meas- 
ure for  the  urine  and  a  pint  measure  for  the  water  serve  the  pur- 
pose of  diluting,  and  these  fluids  must  of  course  be  well  mixed.  If 
higher  dilutions  are  required,  the  drachm  of  urine  may  first  be 
mixed  with  one  or  two  volumes  of  water  before  the  further  dilution 
in  the  pint  measure  is  begun.  One  or  two  rough  experiments  be- 
fore beginning  careful  dilution  may  guide  ns  a5  to  the  num1>er  of 
volumes  with  which  we  should  begin.  Most  albuminous  urines 
can  stand  at  least  one  volume  of  water  being  added,  so  as  to  give 
this  reaction  in  the  time  named  (35 — 45  seconds)  ;  some  may  re- 
quire as  much  as  200  or  even  300  volumes  of  water  to  bring  them 
to  the  necessary  state  of  dilution.  The  state  of  dilution  required 
for  the  reaction  within  the  time  named  is  termed  the  "zei'o;"  each 
volume  of  water  required  to  be  added  is  termed  a  "  degree"  of  this 
scale.  The  value  of  each  degree  was  calculated  by  the  balance  to 
be  equivalent  to  0.00:34  per  cent,  of  albumen.  If  then  a  urine 
showed  250  degrees  of  albumen  we  multiply  by  this  fraction  ; — thus 
250x0.0034:=0.S5  per  cent,  of  albumen;  if  we  wish  to  calculate 
the  total  loss  of  albumen  per  day,  we  multiply  the  number  of 
ounces  passed  by  the  437^  grains  contained  in  an  avoirdupois  ounce, 
multiply  this  again  by  0.85  (as  determined  above)  and  divide  by 
100 :  this  gives  the  answer  in  grains  of  dry  albvimeu. 

In  applying  this  method  we  must,  of  course,  obtain  a  proper 
sample  of  the  whole  urine  passed  in  the  twenty-four  hours. 

In  addition  to  the  estimation  of  the  total  albumen  passed  in  a 
day,  this  method  supplies  by  its  varying  scale  of  degrees  some  defi- 
nite figures  instead  of  vague  ex^^ressions  as  to  the  abundance  of 
albumen  in  urine,  as  "20  degrees,"  "  60  degrees,"  "  100  degrees," 
"200  decrees,"  &c.  (See  Medico-Chirurgical  Transactions,  vol. 
LIX.     Loudon,  1876.) 

The  Clinical  Significance  of  Albcmixuria  is  very 
variable;  it  is  sometimes  of  the  utmost  importance  in  diag- 
nosis, and  at  other  times  of  scarcely  any  account. 

Wlien  due  to  the  presence  of  blood,  pus,  <^'C.  (as  revealed 
by  the  microscope),  the  clinical  significance  of  the  albumen 
turns  of  course  on  the  significance  of  these  ingredients,  and 
must  be  considered  under  these  headings.  Sometimes,  how- 
ever, the  amount  of  albumen  seems  out  of  proportion  to  the 
amount  of  blood,  or  pus  contained  in  the  sample  :  in  such 
cases  the  want  of  a  good  quantitative  test  for  albumen  is 
mucli  felt,  but  an  experienced  eye  can  usually  judge  pretty 
safely  from  a  consideration  of  the  variations  noticed  with 


SIGNIFICANCE    OP    ALBUMINURIA.  365 

different  quantities  of  pus  or  blood.  Sometimes  obvious 
variations  in  the  blood-color  in  different  samples  from  the 
same  case,  with  but  little  change  in  the  quantity  of  albumen 
precipitated  on  heating,  leave  no  doubt  as  to  the  existence 
of  albuminuria,  apart  from,  and  in  addition  to,  the  blood  and 
pus  present. 

Many  acute  febrile  diseases  often  give  rise  to  albuminuria 
for  short  periods,  without  the  diagnosis  or  prognosis  being 
seriously  affected  thereby.  In  typhus  and  enteric  fevers, 
smallpox,  diphtheria  and  malignant  sore  throat,  erysipelas, 
pneumonia,  pleurisy,  pericarditis,  acute  rheumatism,  menin- 
gitis, acute  tuberculosis,  puerperal  fever,  and  acute  suppura- 
tions of  various  kinds,  albuminuria  is  often  detected,  but  it 
must  be  regarded  as  one  of  the  features  of  the  general  dis- 
turbance, rather  than  a  symptom  with  local  significance. 

After  the  primary  fever  of  scarlatina  and  occasionally 
after  smallpox,  enteric  fever,  and  erysipelas,  albuminuria  is 
observed  as  a  recognized  sequela.  In  the  case  of  scarlatina 
indeed,  it  may  be  said  to  be  of  habitual  occurrence,  and 
when  it  appears  in  a  member  of  a  family  affected  with  this 
disease,  or  when  conjoined  in  the  individual  himself  with 
desquamation  of  the  cuticle,  arthritic  pains,  hydrothorax 
and  other  Avell-known  sequelae  of  scarlatina,  it  often  enables 
us  to  recognize  an  attack  of  scarlet  fever  in  a  patient  who 
would  not  otherwise  be  supposed  to  have  been  so  affected. 

In  pregnancy  and  the  puerperal  state  albuminuria  is  not 
infrequent,  and  although  not  necessarily  of  grave  import,  it 
is  always  significant  of  possible  dangers  (convulsions  during 
labor,  chronic  renal  disease,  &c.). 

Chronic  chest  complaints  are  often  complicated  with  albu- 
minuria, and  this  has  great  importance  as  regards  prognosis 
(chronic  bronchitis,  emphysema,  chronic  pneumonia,  pleurisy, 
or  empyema,  heart  disease,  aneurism,  mediastinal  tumors, 
&c.).  Sometimes  in  such  cases  the  albuminuria  is  only  one 
of  the  indications  of  a  general  venous  congestion  which  may 
pass  off  quickly  ;  sometimes  of  a  nephritis  established  through 
the  long  continuance  of  this  renal  congestion  ;  sometimes,  on 
the  other  hand,  the  renal  disease,  of  which  albuminuria  is 
the  sign,  may  be  justly  regarded  as  the  primary  fact,  and 
the  thoracic  affection  as  a  complication. 

1)1  all  dropsies  the  presence  or  absence  of  albumen  is  im- 
portant. Occasionally  genuine  renal  dropsy  exists  Avithout 
albuminuria,  but  this  is  so  rare  as  to  make  such  a  diagnosis 
improbable,    or,   at  least,   it    demands    very   special   proof. 

31* 


866  URINE    AND    URINARY    SYMPTOMS. 

Albuminuria,  on  the  other  liand,  may  be  regarded  as  pre- 
sumiitive  proof  of  a  renal  origin  ibr  the  dropsy,  in  whole  or 
in  part,  but  it  may  be  secondary,  as  just  explained,  to  gen- 
eral venous  obstruction  due  to  cardiac,  hepatic,  or  ovarian 
disease,  or  to  dropsy  of  the  peritoneum,  or  any  other  cause 
giving  rise  to  direct  pressure  on  the  renal  veins. 

In  acute  or  chronic  renal  disease  of  all  kinds,  whether 
with  or  Avithout  dropsy,  the  detection  of  albuminuria  is  of 
the  greatest  value :  concurrent  evidence  from  the  presence 
of  renal  derivatives  in  the  urine  (tube-casts,  epithelium,  &c.), 
from  alterations  in  the  specific  gravity  and  the  quantity  of 
the  secretion,  and  from  the  general  features  of  the  case,  may 
come  in  here  to  help  the  diagnosis. 

In  nervous  diseases,  the  existence  of  albuminuria  is  of 
importance,  but  the  nature  of  its  connection  with  such  cases 
is  variable.  Sometimes  the  nervous  affection  is  a  tolerably 
direct  manifestation  of  the  renal  disease  (urajmic  convul- 
sions, coma,  blindness,  or  delirium) :  sometimes  the  nervous 
affection  is  due  to  organic  changes  associated  with  the  renal 
disease  (hemiplegia  due  to  cei-ebral  hemorrhage  associated 
with  hypertrophy  of  the  heart  and  disease  of  the  kidney). 
At  other  times,  albuminui-ia  may  be  regarded  as  an  effect 
of  the  nervous  disease,  as  in  the  temporary  albuminuria  due 
to  an  epileptic  or  other  convulsive  fit,  or  as  in  the  albumin- 
uria produced  by  certain  forms  of  infiammation,  tumor,  or 
other  lesion  of  the  brain. 

Ii  many  chronic  and  constitutional  affections  we  must 
watch  for  albuminuria ;  phthisis,  syphilis,  scrofulous  disease 
of  the  joints  and  bones,  and  profuse  suppurations  generally, 
are  often  associated  with  albuminuria  due  to  lardaceous 
degeneration  of  the  kidneys.  Cases  of  chronic  indigestion 
and  depressed  states  of  the  health,  with  habitually  alkaline 
urine,  or  with  persistent  deposits  of  oxalate  of  lime,  gouty 
attacks  and  the  like,  must  be  particularly  watched  in  respect 
of  this  symptom,  both  because  of  the  frequent  complication 
of  such  cases  with  albuminuria,  and  because  symptoms  of 
the  class  just  indicated  are  often  the  earliest  manifestations 
of  renal  disease.  Other  chronic  diseases  as  diabetes,  jaun- 
dice, cancer,  exophthalmic  goiti-e,  and  lead  poisoning  are 
often  complicated  with  albuminui-ia. 

Remedial  agents,  especially  blisters,  may  give  rise  to  a 
transient  albuminuria,  sometimes  with,  sometimes  without 
hasmaturia  and  strangury. 

In  the  midst  of  so  many  possible   sources  of  albumen  in 


BLOOD    IN    THE    URINE.  367 

the  urine  we  must  fall  back  on  the  general  symptonas  and 
I'eatures  of  the  complaint  to  guide  our  diagnosis  ;  and  in 
particular,  we  must  have  regard  to  the  persistence  and  to  the 
quantity  of  the  albumen,  and  to  other  evidences  of  derange- 
ments in  the  urine,  as  respects  its  quantity,  its  specific  gra- 
vity, its  color,  and  the  presence  of  tube-casts,  renal  or  other 
epithelium,  pus,  blood,  crystals,  parasites,  &c. 

BLOOD  IN  THE  URINE 

is  always  to  be  regarded  as  important.  Sometimes  its 
appearance  is  so  far  accidental;  thus  the  possibility  of  the 
admixture  of  menstrual  blood  with  the  urine,  or  of  slight 
bleeding  from  the  use  of  the  catheter,  must  be  borne  in 
mind  ;  the  possible  existence  of  more  serious  injuries  to  the 
genito-urinary  organs  must  not  be  ignored,  although  these 
do  not  belong  to  purely  medical  practice. 

Blood  in  the  urine  can  often  be  recognized  by  the  eye  as 
giving  a  dingy  or  smoky  tint  to  the  urine,  especially  when 
the  blood  comes  from  the  kidney  and  is  intimately  mixed 
with  it.  Sometimes  it  has  a  darker  hue,  resembling  choco- 
late. All  gradations  of  red  and  florid  blood-color,  with  or 
without  clots,  may  be  found,  especially  when  the  blood  comes 
from  the  pelvis  of  the  kidney,  the  ureter,  or  bladder.  When 
the  blood  is  present  in  any  distinct  quantity  the  existence  of 
an  albuminous  reaction  may  be  calculated  on  with  certainty, 
and  the  presence  of  this  may  serve  to  confirm  our  sus[)icion 
of  blood,  while  the  absence  of  albumen  should  jnake  us  sus^ 
pect  some  fallacy  as  to  the  blood-tint^  Occasionally,  how- 
ever, the  appearance  of  a  very  distinct  blood-color  may 
co-exist  with  the  merest  trace  of  albumen :  indeed,  it  may 
happen  that  a  reduction  in  the  amount  of  albumen  coincides 
with  the  appearance  of  blood  in  the  urine  in  very  distinct 
quantity.  The  microscope  assists  the  diagnosis  of  haematu- 
ria  by  determining  the  presence  or  absence  of  blood  corpus- 
cles, and  these  may  often  be  seen  in  cases  in  which  no  albu- 
men can  be  detected  by  the  tests.  The  red  blood  corpuscles 
are  recognized  by  their  size  being  smaller  than  that  of  pus, 
or  mucus,  or  white  blood  corpuscles,  and  by  their  having 
the  double  outline  due  to  the  biconcave  character  of  the 
discs  (Fig.  44,  h).  It  frequently  happens,  however,  that  the 
discs  are  swollen  up,  by  absorption  of  fluid,  into  a  globular 
form,  and  this  peculiarity  is  consequently  lost  :  occasionally 
their  edges  are  serrated  from   similar  physical  causes  (Fig. 


368 


URINE    AND    URINARY    SYMPTOMS, 


44,  o,  d).  Sometimes  the  corpuscles  are  so  disintegrated 
that  they  cannot  be  seen,  although  the  coloring  matter  is 
abundantly  present  in  the  urine  ;  in  such  cases  there  may  be 
chocolate-colored  clots  in  the  sediment :  in  these  cases  the 
presence  of  albumen  in  quantity  assists  us  (Ha?matinuria.) 
A  fallacy  is  not  unfrequently  presented  by  globular  vegetable 
spores  closely  simulating  the  microscopic  appearance  of  red 
blood  corpuscles. 


Fig.  44. — Blood  corpuscles  in  nriae.  a.  Slightly  distended  by  imbibition  ;  6, 
Showing  their  biconcave  contour;  c,  Shrivelled ;  d^  Serrated.  (Dr.  William 
Roberts.) 

A  chemical  test  for  blood  (and  for  haemoglobin),  by  means 
of  guaiac^is  sometimes  of  value,  although  subject  to  fallacies 
of  its  own.  Two  or  thr^  ctops  of  the  urine  are  placed  in  a 
test  tube,  a  single  drop  of  tincture  of  guaiac  is  added,  and  a 
few  drops  of  ozonic  ether  are  then  shaken  up  with  the  whole. 
The  ether  dissolves  the  precipitated  resin,  or  goes  to  the  sur- 
face and  carries  up  with  it  a  distinct  bluish  color  if  blood  be 
present.  It  is  alleged  that  this  reaction  can  also  be  obtained 
from  minute  traces  of  h;i?moglobin  \i\  the  urine,  even  before 
the  albumen  appears,  in  scarlatinal  dropsies.  This  test  is 
sometimes  applied  by  means  of  white  bibulous  paper  dipped 
in  the  urine,  the  guaiac  and  ozonic  ether  being  subsequently 
applied  to  the  paper  when  it  has  dried.  If  this  method  be 
followed,  the  paper  itself  must  first  be  tested  with  pure  water, 


CLINICAL    SIGNIFICANCE    OP    HEMATURIA.      369 

as  some  pajiers  give  a  misleading  reaction  ;  high-colored  urine, 
from  bile,  may  also  mislead. 

Clinical  Significance  of  HyEJiATURiA The  appear- 
ance of  blood  in  the  urine  (apart  from  the  accidental  contam- 
inations Trom  the  vagina,  &c.,  already  referred  to)  points 
either  to  some  general  disease,  attended  with  bleeding,  as  in 
the  case  of  purpura,  scurvy,  or  of  some  forms  of  disease  affect- 
ing the  bloodvessels  generally  ;  or  it  may  be  due  to  the  ope- 
ration of  some  poisonous  agency  acting  specially  on  the  kidneys, 
— such  as  cantharides,  turpentine,  creasote,  and  alcohol ;  or 
to  some  local  affection  of  the  urinary  organs  and  passages 
themselves, — such  as  inflammation  of  the  bladder  or  kidneys, 
cancer  of  these  organs,  parasitic  disease  of  the  kidney,  renal 
embolism,  calculus  of  the  kidney  or  bladder  ;  occasionally  it 
is  due  to  the  extension  or  bursting  of  abscesses,  cysts,  &c., 
into  some  part  of  the  urinary  tract  from  adjacent  structures. 

The  further  discrimination  of  such  cases  turns  on  the  as- 
pect of  the  blood,  whether  intimately  mixed  with  the  urine, 
or  florid,  or  in  clots ;  whether  passed  chiefly  with  the  first  or 
the  second  half  of  the  urine  at  a  given  time  ;  whether  asso- 
ciated with  an  excess  of  mucus  or  mingled  with  pus,  and  if  so, 
whether  the  pus  is  exti-emely  variable  in  amount  at  different 
times,  whether  the  reaction  of  the  urine  is  habitually  acid  or 
alkaline  when  passed,  and  whether  any  urinary  gravel,  mi- 
croscopic calculi,  tube-casts,  or  parasites,  are  present  in  the 
sediment.  The  kind  of  epithelium  found  along  with  thefi 
blood  is  often  of  consequence,  if  we  can  recognize  it  as  renal 
or  vesical,  or  as  coming  from  the  pelvis  of  the  kidney  or  the 
ureter.  The  quantity  and  specific  gravity  of  the  urine,  like- 
wise, assist  in  determining  the  presence  of  acute  or  chronic 
disease  of  the  secreting  parts  of  the  kidney.  The  detection 
of  tube-casts  in  a  bloody  urine  always  points  to  a  renal  ele- 
ment in  the  case,  but  it  is  quite  possible  that  even  in  such 
cases  the  bladder  may  be  responsible  for  most  of  tlie  mischief, 
lor  the  renal  affection  may  be  secondary  to  disease  working 
its  way  back  from  the  urethra  and  bladder.  Again,  if  we  can 
satisfy  ourselves  that  there  is  more  albumen  in  the  urine  than 
can  be  accounted  for  by  the  blood  present,  this  also  points  to 
a  renal  affection.  Of  course,  the  general  symptoms  of  the 
case  must  be  strictly  inquired  into,  especially  as  to  pain,  its 
site,  its  area  of  distribution,  whether  over  the  pubes,  in  the 
lumbar  and  sacral  regions,  in  the  thighs,  the  region  of  the 
ureters,  or  in  the  penis,  and  testicles  ;  the  relationship  of  the 
pain  to  the  act  of  micturition,  or  to  any  supposed  cause  of  its 


3*70  URINE    AND    URINARY    SYMPTOMS. 

development,  must  also  be  considered.  (A  surgical  exami- 
nation of  the  urethra,  prostate,  and  bladder,  is  often  demanded 
to  settle  the  questions  here  raised,  at  least  in  cases  of  persist- 
ent or  frequently  recurring  ha^maturia,  associated  with  pain- 
ful micturition.)  Tlie  occurrence  of  shiverings,  the  circum- 
stances under  which  the  hematuria  appeared,  —  whether 
after  scarlatina,  or  in  the  course  of  chronic  or  acute  renal 
diseases,  or  associated  with  hemorrliages  elsewhere,  or  after 
a  fit  of  drinking,  or  in  connection  with  the  use  of  special  drugs, 
or  after  injuries  to  the  parts,  or  in  connection  with  renal  colic 
or  tumor,  and  tenderness  in  the  loins, — all  these  must  be 
inquired  into  ;  their  special  significance  must  be  sought  for  in 
the  description  of  urinary  diseases  in  the  text  books. 

PUS  IN  THE  URINE 

occurs  sometimes  as  a  microscopic  deposit  only ;  at  other 
times  it  appears  in  sufficient  quantity  to  present  a  very  dis- 
tinct and  even  a  bulky  sediment.  In  such  cases  it  may  often 
be  recognized  by  the  naked  eye,  but  it  is  apt  to  be  confounded 
with  pliosphatic  deposits  (especially  as  it  often  exists  along 
with  them),  and  it  may  be  confused  with  white  urates. 
Liquor  potassfe,  as  a  reagent,  may  often  assist  in  the  dis- 
crimination ;  for  urates  are  dissolved  by  this  agent,  phos- 
phates are  but  little  affected  or  rendered  more  dense  by  it, 
while  pus  becomes  ropy  or  gelatinous  on  the  addition  of  an 
equal  bulk  of  liquor  potassse  to  the  purulent  deposit ;  the  im- 
possibility of  pouring  out  such  a  mixture  drop  by  drop  is 
good  evidence  of  this  ropiness.  Sometimes  the  pus  assumes 
this  ropy  character  soon  after  the  urine  is  passed ;  this  is 
due  to  the  development  of  ammonia,  Avhich  acts  on  pus  in 
much  the  same  way  as  liquor  potassaj  does  ;  sometimes  the 
ropiness  exists  when  the  urine  is  passed,  from  the  ammonia- 
cal  decomposition  going  on  within  the  bladder  itself.  The 
microscope  is  useful  in  revealing  the  presence  of  pus  corpus- 
cles ;  these  when  seen  may  be  further  tested  by  the  addition 
of  dilute  acetic  acid,  Avhich  clears  up  the  granular  contents 
and  brings  out  the  tripartite  nucleus.  (See  Fig.  45.)  Other 
white  cells  are  often  found  in  urinary  sediments  which  can 
scarcely  be  distinguished  from  pus ;  the  white  corpuscles  of  the 
blood,  mucus  corpuscles,  inflammatory  corpuscles  (leucocytes), 
and  even  altered  renal  epithelium,  all  resemble  pus  so  closely 
as  to  be  at  times  indistinguishable  from  it.  We  may  judge 
of  the  probability  of  such  cells  being  white  blood  corpuscles 


PUS    IN    THE    UEINE. 


871 


bj  the  presence  or  absence  of  the  red  corpuscles ;  of  their 
being  mucus  corpuscles  by  the  mucous  appearance  or  other- 
wise of  the  sediment ;  renal  epithelial  cells  are  usually  larger 
than  pus,  and  the  action  of  acetic  acid  sometimes  assists  in 
various  doubtful  cases.  The  reaction  of  purulent  urine,  when 
of  renal  origin,  is  usually  distinctly  acid  (if  tested  immedi- 
ately on  being  passed),  even  in  long-standing  suppuration;  it 
is  usually  alkaline  and  ammoniacal  in  long-standing  suppura- 
tion from  the  bladder.  When  of  renal  origin,  the  deposit  of 
pus  in  the  urine  glass  is  often  very  distinctly  demarcated  from 
tlie  supernatant  fluid ;  in  vesical  suppuration,  whether  from 
calculous  irritation  or  not,  it  is  usually  more  diffused  and 
mingled  with  mucus  ;  in  both  cases  it  may  be  mingled  with 
blood  in  various  degrees  and  ways.  In  renal  suppuration, 
the  blood  when  present  usually  lies  in  a  distinct  layer  on  the 
top  of  the  pus ;  in  vesical  cases,  the  blood  is  often  more 
mixed  up  with  the  mucus  and  pus.  Sounding  of  the  bladder 
is  imperatively  called  for  in  all  doubtful  cases  with  bladder 


Fig.  45. — Pus  Cdrpiascles.    «,  Without  reagents  :  6,  After  the  addition  of  acetic 
acid.     (Dr.  Wm.  Roberts.) 

symptoniis.  The  co-existence  of  mucus,  of  fibrous  shreds,  of 
crystals  of  various  kinds,  and  of  epithelium  from  the  kidney, 
ureter,  bladder,  or  urethra,  is  sometimes  of  great  value  in 
judging  of  the  origin  of  the  pus.  If  much  scaly  epithelium 
from  the  vagina  be  present,  leucorrhceal  contamination  should 
at  once  be  suspected,  and  the  use  of  the  catheter  may  be  re- 
quired to  overcome  the  difficulty  of  this  admixture.  Some- 
times in  the  male,  instructive  hints  may  be  gathered  from 
the  relative  abundance  of  pus  in  the  first  half  of  the  urine  as 


372  URINE    AND    URINARY    SYMPTOMS. 

compared  with  the  second,  from  a  single  act  of  micturition  ; 
any  pus  in  the  urethra  is  naturally  washed  away  with  the 
first  half  of  the  urine,  while  if  the  seat  of  suppuration  be  in 
the  bladder,  it  is  I'ather  more  abundant  in  the  second  half, 
and  may  be  more  contaminated  with  blood.  In  suppuration 
from  a  dilated  kidney  the  quantity  of  pus  often  varies  in  a 
remarkable  way  at  different  acts  of  micturition,  and  some  in- 
formation may  be  gained  by  procuring  a  series  of  samples  in 
separate  glasses.  Albumen  can  be  made  out  by  the  tests  in 
all  cases  of  excessively  purulent  urine — ^from  the  presence  of 
the  pus  itself ;  but  when  we  can  make  out  a  greater  amount 
of  albumen  than  the  pus  can  well  account  for,  there  is  a 
strong  case  for  the  renal  origin  of  the  com[)laint ;  we  may 
find,  for  example,  the  same  quantity  of  albumen  present  in 
various  samples,  although  the  pus  may  vary  greatly  and  may 
even  reach  an  insignificant  amount  in  certain  specimens.  It 
is,  however,  often  very  difficult,  or  even  quite  impossible,  to 
get  clear  evidence  of  this,  and  when  blood  as  well  as  pus  is 
present,  the  determination  of  an  independent  albuminuria, 
in  addition  to  these,  becomes  impossible.  As  already  ex- 
plained in  the  case  of  hematuria,  the  detection  of  tube-casts 
is  of  great  value  in  determining  the  presence  of  renal  mis- 
chief of  some  kind  ;  but  these  casts  are  found  in  cases  of  renal 
irritation  from  calculus  and  gravel  as  well  as  in  Bright's  dis- 
ease and  the  other  desti'uctive  lesions  of  the  kidney.  A 
tumor  in  the  loins,  when  present,  often  indicates  for  us  the 
source  of  the  pus  in  the  urine  (pyonephrosis)  ;  and  the  kind 
of  crystals  found  in  the  sediment  may  guide  us  to  a  diagnosis 
of  the  nature  of  the  concretion  in  cases  of  calculous  pyelitis, 
and  of  stone  in  the  bladder. 

The  Clinical  Significance  of  Pus  in  the  Urine 
resembles  somewhat  that  of  hitmaturia,  and  it  is  equally 
varied.  It  may  follow  acute  renal  inflammation,  and  it  often 
appears  in  cases  characterized  by  copious  albuminuria  and 
in  cases  of  Bright's  disease  following  fevers  and  parturition. 
It  occurs  also  in  renal  embolism.  As  already  indicated,  the 
pus  may  proceed  from  abscesses  in  the  substance  of  the  kid- 
ney, or  from  suppuration  of  its  pelvis,  due  to  calculus,  or  to 
secondary  mischief  working  its  way  back  from  the  bladder 
or  urethra.  Pelvic  and  other  abscesses  opening  into  the 
urinary  tracts,  cystitis,  whether  of  calculous  or  paralytic 
origin,  cancer  of  the  bladder,  infiammation  and  suppuration 
of  the  prostate,  gonorrhoea,  and  gleet,  whether  7-ecent  or  of 
old  standing,  may  all  give  rise  to  purulent  urine.    Accidental 


KENAL    TUBE   CASTS.  3T3 

contamination  from  locliial   or  leucorrliocal  discharges  must 
also  be  i-emembered  as  a  possibility. 

RENAL  TUBE-CASTS 

should  always  be  searched  for  in  cases  of  albuminuria.  They 
are  present  in  the  great  majority  of  cases  in  which  the  albu- 
men has  a  renal  origin,  but  they  are  occasionally  so  scanty 
as  to  be  difficult  of  detection.  The  specimen  of  urine  ex- 
amined for  this  purpose  should  have  had  time  to  settle 
thoroughly,  or  for  several  hours  at  least:  the  supernatant 
fluid  should  be  cautiously  poured  off  in  such  a  way  as  not  to 
disturb  the  deposit,  or,  if  we  have  any  further  occasion  for 
it,  some  of  the  sediment  may  be  removed  from  the  bottom 
by  the  pipette,  and  a  drop  placed  on  a  slide  with  a  cover 
glass  may  be  examined  microscopically  with  a  quarter-inch 
lens.  This  suffices  when  the  casts  are  moderately  abundant, 
the  only  precautions  required  being  careful  illumination 
and  focussing.  Many  casts  are  so  transparent  as  to  be  al- 
most invisible  in  a  strong  light,  and  some  shading,  by  moving 
the  mirror,  may  be  required  to  allow  of  their  being  caught 
by  the  eye.  When  scanty,  a  good  plan  is  to  put  several 
drops  of  the  sediment  in  a  shallow  cell  with  a  cover  glass, 
and  examine  with  a  low  power  (half-inch  objective)  ;  or  to 
place  a  drop  or  two  of  the  sediment  on  a  slide,  spread  it  out 
(without  a  cover  glass),  and  pass  the  whole  rapidly  in  review. 
If  a  doubtful  structure  is  seen,  requiring  a  higher  power,  it 
can  be  placed  quite  in  the  centre  of  the  field,  and  the 
stronger  lens  brought  down  upon  it :  or,  as  the  object  glass 
is  thus  apt  to  dip  into  the  fluid,  an  attempt  may  be  made  to 
place  a  cover  glass  over  the  doubtful  structure,  and  after 
finding  it  as  before  with  the  low  power,  we  may  come  down 
upon  it  with  a  stronger  lens  to  define  its  character.  In  this 
way  several  drops  of  the  sediment  may  be  examined  in  rapid 
succession,  and  tube-casts  detected  which  would  otherwise 
have  escaped  notice.  By  filling  the  pipette  with  the  sedi- 
ment, and  allowing  it  to  settle,  either  by  plugging  the  upper 
opening  or  by  leaving  it  to  stand  in  the  urine,  we  sometimes 
obtain  a  better  specimen  for  microscopic  examination  when 
the  sediment  is  scanty  and  the  tube-casts  few  in  number.  In 
other  cases  again,  where  the  field  is  crowded  with  cellular  or 
other  objects,  dilution  with  a  little  water  facilitates  the 
search  for  casts.  If  pipettes  are  used,  care  must  be  taken  to 
have  them  well  cleaned;  owing  to  the  uncertainty  attending 
32 


374 


URINE    AND    URINARY    SYMPTOMS. 


this  cleansing  of  narrow  tubes,  it  is  often  better  to  pour  off 
the  urine  and  examine  a  drop  of  the  deposit  placed  directly 
on  the  slide.  Shreds  of  mucus,  aggregations  of  the  amor- 
phous granules  of  urates,  and  vegetable  growths  sometimes 
assume  forms  which  simulate  tube-casts. 


Fig.  46. — Hyaline,  or  waxy  casts,  a,  From  a  case  of  chronic  Bright's  Disease 
of  eight  months'  duration.  6,  From  a  case  of  chronic  Bright's  Disease  (largo 
white  kidney),  c,  From  a  case  of  chronic  Bright's  Disease  (contracted  kidney, 
with  fatty  degeneration).     (Dr.  Wm.  Eoherts.) 

Tube-casts  are  of  very  various  sizes,  both  as  regards  length 
and  breadth.  When  of  large  diameter  this  should  be  noted, 
as  it  is  a  point  of  some  importance,  as  indicating  a  certain 
dilatation  of  the  renal  tubules.  Tliey  may  be  (1)  perfectly 
"  hyaline,"  i.e.,  clear,  transparent,  and  empty  (see  Fig.  4G); 
(2)  they  may  be  packed  full  of  rows  of  renal  epithelial  cells 
— "  epithelial  casts"  (see  Fig.  47,  a) ;  (3)  the  cells  thus  con- 
tained may  be  quite  fatty,  with  obvious  oily  globules  within 
them,  or  such  globules  may  lie  within  the  cast — "  oily  or 
fatty  casts"  (see  Fig.  48,  a)  ;  (4)  the  fatty  element  may  be 
in  such  a  minute  state  of  division  as  to  present  only  a  dark 
granular  appearance — "  granular  casts"  (see  Fig.  47,  b). 
Various  stages  or  gradations  of  these  four  varieties  are  met 
with,  sometimes  even   in   different  parts  of  the   same  cast. 


SIGNIFICANCE    OF    TUBE-CASTS. 


375 


Fig.  47. — a.  Epithelial  casts.     6,  Opaque  granulai-  casts,  from  a  case  of  acute 
Briglit's  Disease.     (Dr.  Win.  Roberts.) 


Fig.  4S. — a,  Fatty  casts,    h  and  c,  Blood  casts,     d,  Free  fatty  molecules. 
(Dr.  Wm.  Roberts.) 


376  URINE    AND    URINARY    SYMPTOMS. 

In  additioi]  to  these  (5)  the  easts  may  contain  blood-eorpus- 
cles,  and  sometimes  the  coloring  matter  only  of  the  blood — 
"blood  casts"  (see  Fig.  48,  b)  ;  and  in  the  same  way  (G) 
"  pus  casts"  are  sometimes  seen.  In  estimating  the  signifi- 
cance of  these  dififerent  kinds  of  casts  too  much  importance 
should  not  be  attached  to  a  single  specimen  ;  the  character 
of  the  majority  of  the  casts  should  i-ather  be  kept  in  view. 

The  Clixical  Significance  of  Tube-Casts  is  some- 
times considerable,  not  only  in  the  differentiation  of  various 
forms  of  renal  disease,  but  as  indicating  the  actual  existence 
of  a  renal  affection  in  cases  involved  in  doubt.  Thus,  in 
bloody  or  purulent  urine  (as  explained  under  these  head- 
ings), where  the  origin  of  the  blood  or  pus  is  obscure,  the 
existence  of  tube-casts  clearly  points  to  a  renal  element  in 
the  case,  wherever  the  blood  may  come  from.  It  does  not, 
however,  imply  the  existence  of  Bright's  disease,  as  renal 
tube-casts  may  be  associated  with  the  irritation,  arising  from 
a  calculus,  and  they  are  then  sometimes  found  with  blood 
and  crystals,  but  not  necessarily  with  either.  Tube-casts 
are  found  in  jaundiced  urine,  quite  apart  from  any  serious 
renal  affections,  and,  as  a  rule,  apart  even  from  albuminuria. 
With  regard  to  the  different  kinds  of  casts  we  may  say,  in  a 
rough  way,  that  epithelial  casts  and  blood-casts  are  found  in 
the  earliest  stages  of  an  acute  nephritis,  but  very  soon  there- 
after Ave  obtain  hyaline  casts  as  the  predominating  type, 
and  when  the  inflammatory  process  has  gone  on  to  produce 
fatty  changes  in  the  epithelium,  these  changes  are  reflected 
in  the  tube-casts.  Granular  casts  are  found  in  advanced 
cases  of  chronic  disease  of  the  kidneys.  Hyaline  casts  oc- 
cur both  in  recent  and  old  cases.  Tube-casts,  as  a  rule,  are 
abundant  in  eases  of  acute  desquamative  nephritis,  less  abun- 
dant in  the  more  chronic  forms,  and  usually  scanty  in  the 
lardaceous  form  of  renal  disease.  The  exact  forms  of  albu- 
minuria, of  renal  origin,  in  which  tube-casts  are  really  ab- 
sent, cannot  be  strictly  defined :  but  when  inflammatory 
changes  are  absent,  mere  congestion  probably  gives  rise  to 
but  few  casts  (transient  passive  congestion,  exophtlialmic 
goitre,  &c.).  There  is  reason  to  believe  that  a  tube-cast 
may  occasionally  be  detected  in  urine  which  is  practically 
normal. 


EPITHELIUM    FEOM    KIDNEY    AND    BLADDER.      317 


EPITHELIUM 

of  various  kinds  is  often  found  in  urinary  sediments  on  mi- 
croscopic examination,  and  it  is  of  great  importance  to  de- 
tetermine  its  character,  and  if  possible  its  origin.  Renal 
epithelium  lying  loose  is  recognized  as  being  somewhat  glob- 
ular, and  it  can  sometimes  be  compared  with  epithelium 
contained  within  tube-casts  in  the  same  microscopic  field. 
(See  Fig.  47,  a.)  Occasionally  it  resembles  pus  corpuscles, 
and  can  scarcely  be  discriminated  from  thena.  Its  presence 
forms  an  important  element  in  the  diagnosis  of  desquamative 
nephritis,  both  acute  and  chronic.  It  undergoes  various 
changes,  the  cells  appearing  atrophied,  or  granular,  or  dis- 
tinctly fatty.  Sometimes  large  granular  corpuscles  are 
found  along  with  fatty  epithelium  :  these  corpuscles  indeed 
are  themselves  probably  altered  epithelial  cells.  Changes 
of  this  kind  in  the  epithelium  shed  from  the  kidneys  are 
very  suggestive  of  the  processes  going  on  in  these  organs. 
(See  Fig.  49.) 


Pig.  49. — Renal  Epithelium,  a,  Natural  appearance,  h,  Atrophied  and  dis- 
integrated renal  cells,  e,  Renal  cells  in  a  state  of  fatty  degeneration.  (Dr. 
Wm.  Roberts.) 

Cells  from  the  bladder  often  appear  as  groups  of  tesselated 
epithelial  cells  of  circular  form :  sometimes  they  are  pyra- 
midal.    (See  Fig.  50.) 

32* 


378  URINE    AND    URINARY    SYMPTOMS. 


N^4 


•<s> 


Fig.  50. — Epithelial  cells  from  the  bladder,  ureter,  and   pelvis  of  the  kiduey. 
(Dr.  \Vm.  Roberts.) 


Fig.  51. — Vaginal  epithelium  in  the  urine.     (Dr.  Wm.  Roberts.) 


SPEEMATOZOA — FUNGI — VIBRIONES. 


379 


Tailed  ejnthelium  is  found  in  the  ureter  find  pelvis  of  the 
kidney,  and  sometimes  the  recognition  of  such  is  of  value  in 
the  diagnosis  of  calculous  pyelitis.  (See  Fig.  50.)  Large 
scaly  epithelium  is  often  present  as  a  contamination  from  the 
vagina.     (See  Fig.  51.) 

SPERMATOZOA,  BACTERIA,  HAIRS,  FIBRES,  &c. 

Spermatozoa  are  occasionally  seen  in  varying  numbers  in 
the  urine.  They  appear  in  large  numbers  in  the  urine 
after  seminal  emissions,  whether  physiological  or  morbid, 
and  a  few  are  often  inti'oduced  into  the  urinaiy  passages 
during  straining  at  stool,  &c.  When  present  habitually  they 
may  atitbrd  evidence  of  spermatorrhoea.     (See  Fig.  52.) 


Fig.  52. — Spermatozoa.     (Dr.  Wm. 
Roberts.) 


Fig.  5t. — Mould  Fungus.    Sporules  and 
ThaUus.       Dr.  Wm.  Roberts.) 


r<'..\ 


Bacteria^  fungi,  8^c — Bacteria 
and  vibriones  appear  readily  in 
urines  which  stand  some  time,  and 
appear  more  quickly  if  the  reaction 
of  the  urine  be  alkaline  or  if  the 
vessels  used  be  impei-fectly  cleaned. 
They  may  be  found  in  freshly 
passed  urine  if  decomposition  be 
going  on  within  (in  cases  of  paraly- 
sis of  bladder  requiring  catheterization,  &c.)  (See  Fig.  53.) 

Fungi  of  various  kinds,  with  branching  growths,  are  often 
found ;  these  sometimes  resemble  tube-casts.  Spores  of 
globular  shape  likewise  appear  in  various  aggregations  :  when 
single,  they  resemble  blood  corpuscles.     The  rapid  appear- 


,  .53. — Vibriones  in  urine 
(Dr.  Wm.  Roberts.) 


380  URINE    AND    URINARY    SYMPTOMS. 

ance  of  sporules  (torula)  sometimes  directs  attention  to  tlie 
possibility  of  tlie  urine  being  saccharine,  but  torulse  appear 
in  urines  in  which  sugar  cannot  be  detected.  (See  Figs.  54 
and  55.) 


Fig.  55. — Yeast  or  Sugar  Fungus  (Torula  Cerevesise).     Sporules  and  threads  of 
tliallus.     (Dr.  Wm.  Roberts.) 

Foreign  matters. — Cotton,  flax,  fibres,  straw,  hairs,  and 
feathers  are  often  present  in  minute  fragments  from  floating 
dust  from  the  bedding,  &c.  Air-bells  and  oil  globules  (per- 
haps from  an  oiled  catheter  or  an  oily  bottle)  often  puzzle 
the  beginner.     (See  Fig.  56.) 

CRYSTALLINE  AND  AMORPHOUS  DEPOSITS. 

TTric  Acid  can  frequently  be  recognized  as  a  red  sand  in 
the  urinary  deposits,  lying  at  the  very  bottom  and  in  the 
corners  of  the  glass,  or  sometimes  adhering  to  the  sides,  or 
entangled  in  the  mucus.  Although  usually  highly  colored, 
the  uric  acid  crystals  thrown  down  from  pale  urines  are 
sometimes  almost  colorless :  uric  acid  itself  is  without  color,  it 
only  attracts  the  pigment  of  the  urine.  The  forms  presented 
by  uric  acid  crystals  are  very  variable,  but  they  may  mostly 
be  reduced  to  modifications  of  the  rhomb.  The  plates  of 
Dr.  Beale  give  excellent  representations  of  the   variations 


EXTRANEOUS    MATTERS    IN    URINE. 


381 


and  forms  of"  aggregation  usually  met  with.  The  following 
names  applied  by  Dr.  Roberts  to  the  crystals  may  assist  in 
their  recognition : — quadrangular  and  oval  tablets,  cubes, 
six-sided  tablets,  lozenges  and  barrel-shaped  figures,  stars 
and  spikes,  and  fan-shaped  crystals.     (Compare  Fig.  57.) 


Fig.56.— Extraneous  matters  found  in.  Urine  :—CT,  Cotton  fibres  ;  6,  Flax  fibres; 
e,  Hairs;  d.  Air  bubbles  ;  e,  Oil  globules  ;  /,  Wheat  starch  ;  g,  Potato  starch  ; 
h.  Rice-starch  granules  ;  i,  Vegetable  tissue  ;  fc,  Muscular  tissue  ;  I,  Feathers. 

The  presence  of  a  high  color  often  leads  us  to  suspect  the 
nature  of  crystals  which   would  otherwise  be  puzzling,  and 


382 


UEINE  AND  URINARY  SYMPTOMS. 


the  detection  of  transition  forms  from  well-known  shapes 
often  serves  to  confirm  our  conjectures.  Uric  acid  is  very 
insoluble  in  water,  and  it  does  not  disai)pear  on  heating  the 
sediment, — a  distinction  from   the  deposit  of  urates.     Uric 


Fig.  57. — Various  forms  of  Uric  Acid  Crystals.     (Selected  from  Otto  Fuake's 
Physiological  Atlas.) 

acid  is  not  dissolved  by  acetic  acid :  this  serves  to  discrim- 
inate colorless  uric  acid  from  certain  crystalline  forms  of 
phosphate  of  lime.  Uric  acid  is  soluble  in  caustic  alkalies, 
and  alkalies  administered  internally  often  exercise  a  solvent 
power.  Uric  acid  is  sometimes  passed,  as  crystals,  from  the 
bladder,  and  these  may  tlien  be  seen  in  the  fresh  urine  as 
red  particles,  or  as  causing  a  general  turbidity:  they  are, 
however,  more  often  only  formed  and  deposited  by  the  urine 
after  standing  for  a  time  :  this  being  due  partly  to  the  cool- 
ing of  the  urine  and  partly  to  its  increasing  acidity  after  it 
is  passed.  The  crystals  often  increase  in  size  after  a  time. 
The  addition  of  a  drop  or  two  of  strong  acid  to  normal  urine 
precipitates  uric  acid  in  crystals.  Sometimes  the  precipitate 
thrown  down  by  the  addition  of  acid  to  urine  consists  of  a 
dense  mass  of  amorphous  urates  which  may  resolve  itself  by 
and  by  into  uric  acid  crystals.  A  sediment  of  uric  acid 
crystals,  on  being  kept  till  it  becomes  alkaline,  may  be  con- 
verted into  hedge-hog  crystals  of  urate  of  soda. 

Urates  or  Lithates  are  salts  of  uric  acid  combined 


URATES    OR    LITHATES. 


383 


with  soda,  potasli,  or  ammonia,  the  exact  composition  being 
often  veiy  ditficult  of  determination  :  these  bases  would  seem 
often  to  be  mixed  together.  Such  sediments  in  the  urine 
are  extremely  common.  They  are  found  in  urines  which 
are  clear  when  passed,  but  become  turbid  on  cooling  or  after 
standing  for  some  hours.  They  are  occasionally  found  in 
newly  passed  urine,  especially  in  the  cases  of  children  Avho 
pass  milky-looking  urine,  but  in  such  cases  this  sediment,  of 
urate  of  soda,  is  crystalline,  presenting  the  form  of  globules, 
either  simple  or  furnished  with  hedge-hog  projections.  (See 
Fig.  58.)  The  common  form,  however,  consists  in  granules 
of  amorphous  urates  (see  Fig.  59)  ;  these  often  form  aggre- 


Fig.  58. — Hedge-hog  crystals  of 
Urate  of  Soda,  spontaneously  de- 
posited from  the  urine  of  a  child. 
(Dr.  Wm.  Eoberts.) 


Fig.  .59. — Amorphous  Urate  deposit. 
(Dr.  Wm.  Eoberts.) 


gations  so  as  to  assume  the  shape  of  ropes  or  strings,  simu- 
lating occasionally  granular  tube-casts.  The  microscope 
cannot  always  discriminate  amorphous  urates  from  an  amor- 
phous deposit  of  earthy  phosphates,  but  the  reaction  usually 
settles  the  point :  urates  are  deposited  on  cooling  from  acid 
urines :  phosphates  are  found  with  an  alkaline  or  at  least  a 
neutral  reaction.  The  use  of  liquor  potassaj  likewise  assists, 
as  also  the  action  of  heat ;  both  of  these  dissolve  a  sediment 
of  urates,  but  leave  phosphates  unaffected  or  may  even  ren- 
der such  a  sediment  more  dense.  The  sediments  of  urates 
are  usually  fawn-colored,  or  pinkish,  or  even  as  red  as  blood. 
The  chemical  causes  of  the  precipitation  may  be  considered 
as  connected  with  the  cooling  of  the  urine,  its  concentration 


384 


URINE    AND    URINARY    SYMPTOMS. 


(from  febrile  disorders  or  from  scanty  supply  of  fluid),  and 
also  with  the  increasing  acidity  of  the  urine  after  it  is  passed. 
Adding  a  little  acid  sometimes  precipitates  urates  in  a  urine 
in  which  they  are  deposited  spontaneously  in  the  course  of  a 
day  or  two.  The  internal  administration  of  alkalies  or  dilu- 
ents often  accounts  for  the  disappearance  of  these  sediments 
under  observation. 

Phosphates  appear  in  two  distinct  forms,  amorphous  and 
crystalline  :  the  crystalline  phosphates  are  of  two  classes,  the 
ciystallized  phosphate  of  lime  and  the  ammonio-magnesian 
(or  "  triple")  phosphate.  The  phosphatic  deposits  oiten  form 
a  white  sediment  somewhat  resembling  pus. 


Fig.  60. — Ammonio-Magnesian  (triple)  Phosphates.     (Selected  to  show 
■various  forms.) 

The  ammonio-magnesian  {or  triple)  phosphate  is  the 
commonest  variety,  and  it  may  appear  in  almost  any  urine 
which  is  kept  till  it  decomposes,  as  the  urea  thus  supplies 
the  ammonia  for  these  crystals.  The  crystals  are  usually 
prismatic.  They  often  form  on  the  surface,  appearing  as  a 
glittering  scum,  or  the  glittering  prisms  may  be  seen  on  the 
sides  of  the  glass,  or  entangled  in  the  mucus  or  purulent 
sediment.  The  reaction  of  such  urine  is  usually  alkaline, 
but  it  may  be  neutral  or  faintly  acid.  Such  crystals  are 
sometimes  to  be  seen  in  the  urine  as  it  is  passed,  especially 
associated  with  pus,  and  with  an  ammoniacal  odor,  from  the 
decomposition  going  on  within  the  bladder.  The  forms  of 
the  crystals,  althougli  essentially  prismatic,  undergo  various 
alterations,  and  sometimes  they  assume  a  feathery  appearance. 
(See  Fig.  GO.) 


OXALATE    OF    LIME. 


385 


Crystallized  phosphate  of  lime  appears  usually  as  stars  or 
rods,  or  as  fan-shaped  crystals,  destitute  of  color:  other 
forms  are  also  occasionally  met  with.  The  action  of  acetic 
acid  is  sometimes  useful  in  distinguishing  them  from  uric 
acid  crystals,  as  the  phosphates  are  dissolved  by  this  acid  and 
uric  acid  is  not.     (See  Fig.  61.) 


rig.  61. — Crystallized  Piiosphate  of  Lime.     (Selected  to  show  'various  forms.) 

Amorphous  sediments  of  earthy  phosphates  are  occasion- 
ally met  with  in  freshly  passed  urine,  apart  from  disease, 
giving  the  urine  a  slightly  milky  appearance :  this  arises 
from  an  accidental  alkalinity  of  the  secretion,  due  perhaps 
to  the  kind  of  food  taken  immediately  before.  Boiling  the 
urine  often  precipitates  the  earthy  phosphates  in  alkaline  or 
feebly  acid  urines,  so  that  the  action  of  alkalies  and  heat  on 
them  is  exactly  the  reverse  of  what  we  find  with  urates. 
The  sediment  when  unmixed  with  other  deposits  is  at  once 
dissolved  on  the  addition  of  acetic  acid. 

Oxalate  of  Lijie  deposits  can  sometimes  be  recognized 
by  the  naked  eye  as  causing  a  very  fine  powdery  sediment 
dusted,  as  it  were,  over  a  delicate  cloud  of  mucus.  These 
sediments  occur  in  acid  urines  and  disappear  if  the  urine 
be  rendered  alkaline  by  medicines.  The  crystals  are  octo- 
hedral  in  shape,  but  appear  at  times  in  somewhat  different 
forms  (single  or  doable  pyramids).  Occasionally  they  are 
found  in  the  form  of  dumb-bell,  or  ellipsoidal,  or  reniform 
crystals.     (For  the  various  forms  see  Fig.  62.) 

Oxalate  of  lime  crystals  are  sometimes  passed  as  such 
from  the  bladder  (indeed  the  dumb-bell  crystals  are  alleged 
33 


386  URINE    AND    URINARY    SYMTTOMS. 

to  be  sometimes  formed  within  the  tubules  of  the  kidney), 
but  oxalate  of  lime  is  usually  crystallized  out  of  the  urine 
after  it  has  passed,  and  the  dimensions  of  the  crystals  can 
often  be  seen  to  increase  with  keeping.  Oxalate  of  lime  is 
insoluble  in  acetic  acid  ;  this  is  at  times  useful  in  distinguish- 
ing some  of  the  unusual  forms  from  phosphates.  Aggrega- 
tions of  minute  crystals  or  miscroscopic  calculi  are  sometimes 
formed  of  minute  dumb-bell  or  pyramidal  crystals. 


Fig.  62. — Oxalate  of  Lime  Crystals.     (Selected  to  show  various  forms.) 

Other  crystalline  deposits  are  occasionally  found  in 
urine  ;  Carbonate  of  lime  in  little  balls,  Cystine  in  six-sided 
tablets,  Tyrosine  in  needles,  Cholesterine  in  scales,  &c.,  but 
these  are  all  somewhat  rare. 

The  Clinical  Significance  of  AMORPHors  and  crys- 
talline deposits  is  not  so  great  as  that  of  pus,  blood,  and 
tube-casts. 

Uric  acid  occurring  habitually  as  a  sediment,  or  even  the 
persistence  of  urates  as  a  deposit,  indicates  a  derangement 
in  the  health,  pointing  to  some  error  in  the  digestive  or 
hepatic  functions,  and  having  perhaps  some  relation  to  the 
gouty  diathesis  (Lithiasis,  Lithoemia).  Very  red  urates  are 
so  frequently  associated  with  liver  disease  as  to  be  useful  in 
directing  attention  to  this  organ.  The  occasional  occurrence 
of  urates  on  the  cooling  of  the  urine  has  no  real  importance, 
and  uric  acid  crystals  may  likewise  appear,  at  a  time,  with- 
out any  special  significance.  It  is  the  habitual  or  excessive 
occurrence  of  these  which  is  important.  They  sometimes 
appear  at  the  crisis  of  fevers,  «fcc. 

Oxalates  of  lime,  in  like  manner,  when  deposited  habit- 
ually and   excessively,  and  in   urines  loaded  wdth  urea,  is 


SIGXIFICANCE    OF    CRYSTALLINE    DEPOSITS.       387 

often  found  associated  with  a  train  of  nervous  and  dyspeptic 
symptoms  whicli  have  been  grouped  together  and  named 
"oxaluria,"  and  are  supposed  by  some  to  indicate  an  "oxalic 
acid  diathesis."  Oxalates  are  frequently  present  in  the  urine 
in  nervous  affections  of  various  kinds.  It  must  be  under- 
stood, however,  that  a  few  oxalates  frequently  appear  in  the 
urine  apart  from  any  obvious  derangement  of  the  health. 
The  uric  acid  and  the  oxalic  acid  diatheses  seem  to  have 
certain  affinities  ;  the  former  is  certainly  hereditary  ;  it  seems 
to  be  interchangeable  with  the  latter  in  some  members  of  the 
same  family,  and  perhaps  at  different  periods  of  the  same 
person's  history. 

As  associated  with  signs  and  sj'mptoms  of  renal  and 
vesical  culculus  and  gravel,  the  a])pcarauce  of  either  uric 
acid  or  oxalate  of  lime  crystals  is  often  of  great  importance 
in  diagnosis  and  in  guiding  the  treatment.  These  crystals, 
Avhen  associated  with  blood,  tube-casts,  or  pus,  often  point  to 
the  site  and  nature  of  the  illness.  The  hedge-hog  crystals 
of  urate  of  soda  may  likewise  be  sources  of  renal  and  vesical, 
or  urethral  irritation,  and  of  calculus. 

Crystallized  phosphate  of  lime  has  been  supposed  to  indi- 
cate the  existence  of  serious  organic  disease  attended  with 
waste  of  tissue  (phthisis,  diabetes,  paralysis).  It  certainly  is 
frequently  met  Avith  in  serious  nervous  affections. 

The  triple  phosphates  (ammonio-maguesian  phosphates) 
have  not  much  significance  unless  when  detected  in  freshly 
passed  urine ;  they  then  indicate  that  a  process  of  decompo- 
sition is  going  on  within  the  bladder ;  they  may  likewise 
indicate  the  nature  of  visical  concretions  in  the  process  of 
formation. 

Persistent  deposits  of  the  amorpohus  earthy  phosjjhates 
being  associated  with  habitual  alkalinity  of  the  urine,  are  not 
unfrequently  the  index  of  a  depressed  state  of  health  ;  they 
may  also  tend  to  vesical  concretions.  A  similar  remark  ap- 
plies to  carbonate  of  lime.  Tyrosine  crystals  are  occasionally 
found  in  typhus  and  other  fevers,  and  especially  in  cases  of 
acute  yellow  atrophy  of  the  liver ;  the  urine  usually  requires 
to  be  evaporated  down  to  obtain  these  crystals.  The  clinical 
significance  of  cystine  is  not  yet  clearly  made  out ;  it  may 
form  the  nucleus  of  a  calculus. 


388  URINE    AND    URINARY    SYMPTOMS. 

SCHEME    OF  SYSTEMATIC   QUALITATIVE  ANALYSIS 
OF  UBINARY  CALCULI  {Thudicum). 

PoM-der  the  calculus.  Heat  a  small  portion  of  the  powder  to 
redness  on  some  platinum  foil,  and  observe  ■whether  any  residue  is 
left  which  will  not  burn  off. 

A.  In  case  it  leaves  a  fixed  residue,  take  a  small  portion  of  the 
original  calculus,  dissolve  in  concentrated  nitric  acid,  evaporate  to 
dryness  on  a  water  bath  in  a  white  porcelain  evaporating  dish  ;  dip 
a  glass  rod  into  the  strongest  ammonia,  and  bring  it  near  the 
residue  in  the  dish,  and  observe  whether  a  pink  color  is  produced 
or  not. 

I.  A  pink  color  is  produced,  proving  that  the  calculus  contains 
uric  acid;  observe  whether  a  portion  of  the  calculus  melts  on  being 
heated. 

a.  It  melts — 

(1)  And  communicates  a  strong  yellow  color  to  the  flame  of  a 
spirit  lamp  or  Bunsen  burner ;  sodium  urate. 

(2)  And  communicates  a  violet  color  to  the  flame,  giving  the  po- 
tassium spectrum ;  potassium  urate. 

b.  It  does  not  melt ;  dissolve  the  residue  left  after  ignition  in  a 
little  dilute  hydrochloric  acid,  add  ammonia  till  alkaline,  and  then 
ammonium  carbonate  solution. 

(1)  A  white  precipitate  falls  ;  calcium  urate. 

(2)  No  precipitate  :  add  somehydric  sodic  phosphate  solution  ; 
a  white  crystalline  precipitate  falls  ;  magiitsium  urate. 

II.  No  pink  color  is  produced.  Observe  whether  a  portion  of  the 
calculus  melts  on  being  heated  strongly : — 

a.  It  melts  (fusible  calculus).  Treat  the  residue  with,  acetic 
acid  :  it  dissolves  ;  add  to  the  solution  ammonia  in  excess  ;  a  white 
crystalline  precipitate  falls  :  ammonio  ijiacjiiesium  phosphate.  In  case 
the  melted  residue  is  insoluble  in  acetic  acid,  treat  with  hydro- 
chloric acid ;  it  dissolves.  Add  to  the  solution  ammonia  ;  a  white 
precipitate  indicates  ccdcium  phosphate. 

h.  It  does  not  melt ;  moisten  the  residue  with  water  and  test  its 
reaction  Mith  litmiis  paper  ;  it  is  not  alkaline.  Treat  with  hydro- 
chloric acid,  it  dissolves  witliout  effervescence.  Add  to  the  solu- 
tion ammonia  in  excess,  white  precipitate  :  calcixnn  phosphate.  Treat 
the  calculus  with  acetic  acid  ;  it  does  not  dissolve.  Treat  the  resi- 
due after  heating  with  acetic  acid,  it  dissolves  with  effervescence  ; 
calcium  oxalate.  Treat  the  original  calculus  with  acetic  acid,  it  dis- 
solves with  effervescence  ;  calcium  carhonate. 

B.  The  calciilus  on  being  heated  does  not  leave  a  fixed  residue. 
Treat  a  portion  of  the  calculus  with  nitric  acid,  evaporate  and  ex- 
pose to  ammonia  vapor  as  before. 

I.  A  pink  color  is  developed. 

a.  Mix  a  portion  of  the  jjowdered  calculus  with  a  little  lime 
and  moisten  with  a  little  water  ;  ammonia  is  evolved,  and  a  red 
litmus  paper  suspended  over  the  mass  is  turned  blue  ;  ammonium 
urate. 

b.  No  ammonia  ;  uric  acid. 


BILE    IN     URINE.  389 

11.  No  pink  color  is  developed. 

a.  But  the  nitric  acid  solution  turns  yellow  as  it  is  evaporated, 
and  leaves  a  residue  insoluble  in  potassium  carbonate  ;  xdnthine. 

h.  The  nitric  acid  solution  turns  dark  brown  and  leaves  a  residue 
soluble  in  ammonia  ;  cystine. 

BILE  IN  URINE 

can  often  be  recognized  by  the  eye  when  present  in  any 
quantity.  Moreover,  when  testing  for  albumen  by  nitric 
acid,  the  peculiar  greenish  reaction  produced  by  bile  usually 
attracts  attention.  More  delicately  applied,  this  test  with 
nitric  acid  consists  in  placing  a  drop  or  two  of  urine  and  a 
drop  or  two  of  strong  nitric  acid  on  adjacent  parts  of  a 
Avhite  plate,  and  allowing  the  one  to  run  into  the  other. 
The  commingling  of  the  Huids  should  be  closely  watched  in 
good  daylight,  when  a  beautiful  play  of  colors  is  observed — 
including  brown,  green,  blue,  violet,  red,  and  yelloAV.  Or, 
a  little  acid  may  be  dropped  on  the  urine  as  placed  on  a 
plate,  or  on  a  white  sheet  of  note  paper,  when  a  similar 
reaction  occurs.     This  test  applies  only  to  hile  pigment. 

A  test  for  the  biliary  acids  has  been  introduced,  but  it 
does  not  give  reliable  results  as  applied  to  urine.  Two 
drachms  of  urine  are  introduced  into  a  test  tube,  a  small 
piece  of  loaf  sugar  is  added,  and  a  drachm  of  strong  sul- 
phuric acid  is  poured  gently  down  the  sides  of  the  glass  ;  if 
the  biliary  acids  are  present,  a  deep  purple  color  is  produced 
at  the  line  of  junction ;  a  brown  instead  of  a  purple  color 
indicates  their  absence.  This  test,  however,  has  not  been 
found  of  much  clinical  value. 

The  Clinical  Significance  of  Bile  in  the  Urine  corresponds 
with  that  of  Jaundice  (see  p.  332).  Its  presence  or  absence 
assists  in  the  differentiation  of  discolorations  of  the  skin  or 
of  the  conjunctiva,  due  to  other  causes.  It  likewise  seems 
occasionally  to  indicate  an  incipient  jaundice  before  the  tis- 
sues generally  are  affected,  and  its  disappearance  from  the 
urine  sometimes  affords  evidence  that  the  attack  is  passing 
off,  although  the  jaundice  elsewhere  may  still  remain  very 
visible.  The  presence  of  bile  pigment  may  serve  to  explain, 
so  far,  the  existence  of  tube-casts  in  urine,  as  already  noticed, 
under  the  heading  of  Tube-Casts,  or,  at  least,  to  give  their 
presence  a  less  serious  significance  (see  p.  376). 

33* 


390  TRTXE    AND    TRINART    SYMPTOMS. 


CHLORIDES 

are  always  present  abundantly  in  normal  nrine.  They  are 
often  diminished,  or  almost  suppressed,  in  several  febrile  dis- 
eases, especialh'  in  pneumonia.  The  quantity  may  be  roughly 
determined  by  adding  a  little  of  a  strong  solution  of  nitrate 
of  silver  to  the  urine,  along  with  a  few  drops  of  strong  nitric 
acid.  The  denseness  of  the  precipitate,  or  its  relative  abun- 
dance when  the  sediment  falls  down,  serves  to  indicate  the 
quantity;  a  sample  of  normal  urine,  treated  in  the  same 
■way,  may  be-  used  as  a  basis  of  comparison.  This  precipi- 
tate of  the  chloride  of  silver  (insoluble  in  nitric  acid)  is 
soluble  in  ammonia.  Albumen,  if  present,  must  be  sepa- 
rated before  testing  for  chlorides,  as  it  also  is  thrown  down 
by  nitrate  of  silver. 

THE  ESTIMATION  OF  UREA 

contained  in  urine  aifords  valuable  data  in  certain  physio- 
logical and  pathological  inquiries.  It  has  been  made  out, 
however,  that  the  quantity  of  nitrogen  eliminated  by  the 
urine  depends  more  on  the  quantity  taken  in  as  food  than  on 
anything  else,  so  that  if  we  aim  at  scientific  precision,  an 
analysis  of  the  food  taken  is  almost  required  to  give  value  to 
the  quantitative  analysis  of  the  urea.  Albumen,  if  present, 
should  be  separated  by  boiling,  before  beginning  the  estima- 
tion of  the  urea.  The  natural  excretion  of  ui-ea  may  be 
quoted  roughly  at  .500  grains  per  day  for  a  male  adult,  or  3^ 
grains  per  pound  weight  of  his  body  (33.18  grammes,  or  .500 
gramme  per  1  kilo,  of  body-weight). 

The  specific  gravity  of  the  urine  (in  the  absence  of  sugar) 
usually  gives  a  fair  indication  of  the  quantity  of  urea  being 
excreted.  Occasionally,  by  the  rapid  crystallization  of  ni- 
trate of  urea,  on  the  addition  of  nitric  acid  to  the  urine,  we 
have  evidence  of  its  presence  in  excess.  For  very  accurate 
results,  probably  the  best  plan  is  to  determine  the  total  ni- 
trogen, by  the  ordinary  processes  followed  by  chemists  in  an 
ultimate  organic  analysis  ;  but  this,  of  course,  is  not  available 
in  clinical  practice. 

Two  volumetric  processes  for  the  estimation  of  urea  are 
employed,  both  of  which  afford  moderately  accurate  results. 

Liebig's  Method  is  leased  on  the  principle  of  tlie  precipitability 
of  urea  bj  mercuric  nitrate,  and  further,  on  the  circumstance  that 


liebig's  process  for  estimating  urea.    391 

the  white  precipitate  thereby  produced  is  not  decomposed,  and 
therefore  not  tui'ned  yellow  by  carbonate  of  sodium.  (This  yellow 
color  results  from  the  formation  of  oxide  of  mercury,  or  basic  nitrate 
of  mercury,  or  carbonate  of  mercury.)  It  is  necessary  also  to  sepa- 
rate from  the  urine,  before  operating  on  it,  the  phosphates  and  sul- 
phates, so  that  the  urine  requires  first  to  be  prepared  by  treating 
it  with  baryta-water  and  a  solution  of  nitrate  of  barium.  A  further 
preliminary  proceeding  consists  in  determining  the  quantity  of 
chloride  of  sodium  present,  as  the  reaction  does  not  occur  till  the 
whole  of  the  chloride  of  sodium  is  decomposed  and  converted  into 
nitrate  of  sodium.  This  may  be  estimated  by  noticing  the  amount 
of  mercurial  solution  added  from  the  burette  before  the  white  pre- 
cipitate begins  to  appear  ;  or  the  amount  may  be  determined  more 
accurately  by  precipitation  with  silver.  A  further  ditficulty  arises 
from  the  fact  that  this  mercury  process  is  only  accurate  when  tlie 
proportion  of  the  urea  in  solution  amounts  to  two  per  cent.,  so  that 
an  allowance  must  be  made  in  carrying  out  the  process  wlien  the 
results  indicate  that  more  or  less  than  this  amount  is  actually  pre- 
sent. 

It  is  somewhat  difficult  to  prepare  accurately  in  its  proper  strength 
the  solution  of  mercuric  nitrate  ;  indeed,  the  most  satisfactory  way 
is  to  dilute  a  solution  of  pure  mercuric  nitrate  so  as  to  correspond 
with  a  definite  quantity  of  urea  when  this  has  been  ascertained  by 
precipitation  from  a  pure  solution  of  urea  in  water.  The  solution 
may  also  be  purchased  from  certain  makers.  (Griffin,  Bunhill 
Row,  London.) 

Details  of  Liebig's  Method. — (Dr.  Michael  Foster,  Watts's  Dic- 
tionary of  Chemistry,  "Urine,"  vol.  v.,  p.  966,  London,  1874.)  Pre- 
pared urine  (if  albumen  be  present  it  must  be  separated  hy  boiling, 
some  urea  will  probably  be  lost).  Two  volumes  of  urine  are  mixed 
with  one  volume  of  a  "  baryta  mixture"  (consisting  of  two  volumes 
of  baryta-water  to  one  volume  of  a  solution  of  barium  nitrate,  both 
saturated  in  the  cold),  and  filtered. —  Ureu-sohtion :  2  grammes  of 
pure  urea  are  dissolved  in  water  and  the  solution  diluted  to  100 
c.  c. — Mercurial  solution :  a  concentrated  solution  of  pure  mercuric 
nitrate  is  diluted  with  four  times  its  bulk  of  water.  10  c.  c.  of  tlie 
urea  solution  are  measured  into  a  beaker,  and  the  mercurial  solu- 
tion is  slowly  added  from  a  burette  as  long  as  any  precipitation 
takes  place ;  a  drop  of  the  mixture  is  then  let  fall  by  a  glass  rod 
into  a  drop  of  a  solution  of  sodic  carbonate  (say  about  20  grains  to 
ounce)  placed  in  a  watch-glass,  or  on  a  glass  plate,  over  some  black 
surface.  If  the  precipitate  which  occurs  on  the  mingling  of  the 
two  drops  does  not  become  in  a  few  seconds  distinctly  yellow,  more 
of  the  mercurial  solution  must  be  added  to  the  mixture  in  the 
beaker  and  the  trial  made  again.  As  soon  as  a  distinct  yellow  color 
appears  (the  shade  being  noticed  by  the  observer  in  order  to  guide 
him  afterwards),  the  trial  drops  are  returned  into  the  beaker,  and 
a  little  of  the  soda-solution  added  until  the  mixttire  is  only  faintly 
acid.  A  drop  is  then  again  to  be  tried  with  the  soda-solution,  and 
if  the  yellow  color  does  not  show  itself,  a  small  quantity  of  the 
mercurial  solution  must  still  be  added  to  the  mixture  in  the  beaker 
and  the  trial  made  again.  When  the  yellow  color  has  been  thus 
obtained,  the  total  quantity  of  mercurial  solution  used  is  read  off  ; 


392  URINE    AND    URINARY    SYMPTOMS. 

it  corresponds  to  .2  gramme  urea.  The  mercurial  solution  itself  is 
then  diluted  according  to  these  results,  so  that  20  c.  c.  of  it  corre- 
spond to  10  grammes  of  the  urea  solution,  i.  e.,  so  that  10  c.  c.  corre- 
spond to  .1  gramme  urea.  It  is  well  not  to  add,  at  once,  the  whole 
of  the  water  required,  but  to  stop  a  little  short  of  that  and  titrate 
again,  since  j^ractically  the  degree  of  dilution  required  is  rather 
less  than  that  suggested  by  calculation. 

Method.  Of  the  prepared  urine  15  c.  c.  (corresponding  to  10  c.  c. 
of  the  original  urine)  are  poured  out  into  a  beaker  or  flask,  and  the 
mercurial  solution  is  added  until  tlie  yellow  reaction,  as  described 
above,  is  obtained  ;  the  mixture  is  also  in  the  same  way  reduced  in 
acidity  and  trial  made  again.  The  quantity  of  mercurial  solution 
used  will  give  the  amount  of  urea  in  the  10  c.  c.  of  urine.  Unfor- 
tunately the  reaction  is  exact  only  for  fluids  containing  2  per  cent, 
of  urea ;  its  appearance  is  premature  when  more,  and  is  delayed 
when  less  than  that  percentage  is  present.  If  the  prepared  urine 
contains  an  excess  of  urea,  double  its  volume  of  the  mercurial  sola 
tion  will  have  been  used  and  yet  no  reaction  set  in.  Hence  if,  on 
arriving  at  this  point,  1  c.  c.  of  distilled  water  be  added  to  the  mix- 
ture for  every  additional  2  c.  c.  of  the  mercurial  solution  employed, 
the  proi^ortion  of  urea  will  be  maintained  at  2  per  cent.,  and  the 
final  result  will  be  correct.  Thus  if  after  the  addition  of  30  c.  c. 
of  the  niercurial  solution  to  15  c.  c.  of  the  prejjared  urine  the  re- 
action is  not  seen,  1  c.  c.  of  distilled  water  is  added  and  the  process 
continued.  Supposing  the  reaction  finally  sets  in  M'hen  10  c.  c. 
more,  or  40  c.  c.  in  all,  of  the  mercurial  solution  have  been  used, 
the  5  c.  c.  of  distilled  water,  which  have  been  also  added,  will  bring 
np  the  original  15  c.  c.  of  urine  to  20  c.  c.  ;  the  40  c.  c.  of  mercurial 
solution  will  have  been  employed  on  a  fluid  containing  2  per  cent, 
of  urea. 

If  the  prepared  urine  contains  less  than  2  per  cent,  of  urea  an 
approximate  correction  may  be  made  by  subtracting  .1  c.  c.  from 
every  5  c.  c.  of  the  mercurial  solution  that  is  run  short  of  the  nor- 
mal 30  c.  c.  Thus,  if  with  15  c.  c.  of  prepared  urine  the  yellow 
color  is  struck  on  using  20  c.  c.  of  the  mercurial  solution,  .2  c.  c. 
(30 — 20:=  5X2)  are  deducted,  and  therefore  19.8  c.  c.  taken  as  the 
correct  result.  A  further  correction  must  be  made  for  chloride  of 
sodium,  the  presence  of  which  delay's  the  reaction.  We  may  make 
an  approximate  correction  by  deducting  from  the  quantity  of  mer- 
curial solution  employed  1.5  c.  c— 2.5  c.  c,  according  to  the  quan- 
tity of  chloride  of  sodium  present.  Or  we  may  first  remove  the 
chloride.  To  15  c.  c.  of  prepared  urine  one  or  two  drops  of  solution 
of  neutral  chromate  of  potash  are  added,  and  a  solution  of  nitrate 
of  silver  dropped  in  from  a  burette,  until  the  appearance  of  the 
red  chromate  of  silver  indicates  that  the  whole  of  the  chloride  has 
been  thrown  down  ;  the  mercurial  solution  can  then  be  at  once 
used  without  removing  the  silver  precipitate.  The  reduction  in 
the  percentage  of  urea  by  the  addition  of  the  silver  solution  must 
of  course  be  taken  into  account.  Or  two  proportions  of  prejjared 
iirine  may  be  taken  of  15  c.  c.  each.  One  is  neutralized  with 
nitric  acid,  the  mercurial  solution  added,  and  the  point  marked  at 
which  a  permanent  precijjitate  (a  distinct  cloud,  not  a  mere  opal- 
escence) is  produced.    The  other  is  titrated  in  the  usual  way.  The 


HYPO-BROMITE    OF    SODIUM    PROCESS. 


393 


number  of  c.  c.  employed  in  the  latter,  minus  tliose  employed  in 
the  former  operation,  will  give  the  real  quantity  of  urea. 

It  must  be  remembered  that  other  nitrogenous  bodies,  creatinine, 
allantoin,  &o.,  are  precipitated  by  the  mercurial  solution  in  the 
same  way  as  urea. 

Hypo-Bromitb  of  Sodium  Peocess  for  Estimating  Urea. — Davy's 
process  (by  hypo-chlorite  of  sodium)  has  been  modified  and  adapted 
for  clinical  purposes  by  Esbach  of  Paris,  Russell  and  West,  and 
Apjohn.  The  process  consists  in  estimating  the  quantity  of  nitro- 
gen given  off  when  a  solution  of  urea  is  mixed  with  a  hypo-bromite 
solution.  This  last  named  solution  is  very  readily  clianged  by 
keeping,  and  so  must  be  made  fresh.  It  is  composed  of  100  gram- 
mes of  caustic  soda,  250  c.  c.  of  water,  and  25  c.  c.  of  bromine,  all 
shaken  up  together.  (Of  course  the  soda  solution  can  be  kept  and 
the  bromine  added  in  proper  proportion  when  wanted,  so  as  to  be 
used  fresh.)  Tlie  following  is  the  description  of  Apjohn's  process 
{Chemical  Neivs,  Jan.  22,  1875.)  The  instruments  are  such  as  may 
be  found  in  any  laboratory  ;  they  are  :  (1)  A  glass  measuring  tube 
of  about  a  foot  in  length,  drawn  out  at  the  end,  which  will  be  up- 
permost when  the  tube  is  used,  like  a  Mohr's  burette,  and  sub- 
divided into  30  parts  of  equal  capacity,  the  aggregate  volume  of 
which  is  55  c.  c.  (2)  A  small  wide  mouthed  gas  bottle  of  about 
60  c.  0.  capacity.  (3)  A  short  test-tube  of  about  10  c.  c.  capacity, 
of  such  a  height  that  when  introduced  into  the  gas  bottle  it  will 
stand  within  it  in  a  slightly  inclined  position.     (See  Fig.  ()3.) 


Fig.  63. — Apjohn's  Apparatus  for  the  estimation  of  Urea  by  the 
hypo-hrornite  of  sodium  solution. 


The  following  are  the  arrangements  for  combining  the  apparatus 
and  working  an  experiment :  The  graduated  tube,  held  in  a  clamp 
attached  to  a  retort  stand,  is  depressed  into  a  glass  cylinder,  nearly 
filled  with  water  until  tlie  zero  mark,  which  is  near  the  ufjper  end, 
exactly  coincides  with  the  surface  of  the  water.     15  c.  c.  of  the 


394  URINE    AND    URINARY    SYMPTOMS. 

liyi^o-bromite  solution  having  been  poured  into  the  llask,  th(3  test- 
tube  containing  the  urine  is  introduced  by  means  of  forceps,  care 
being  taken  that  none  of  its  contents  shall  spill  into  the  liypo- 
bromite.  The  flask  is  now  closed  with  a  very  accurately  fitting 
India-rubber  stopper,  perforated  with  a  hole  in  which  is  inserted  a 
short  piece  of  glass  tubing  open  at  both  ends,  and  is  then  con- 
nected with  the  measuring  tube  by  means  of  a  piece  of  elastic 
tubing.  It  is  now  inclined  so  as  to  allow  the  urine  to  mix  with 
the  hypo-bromite.  Effervescence  at  once  commences,  and  as  it  pro- 
ceeds the  measuring  tube  is  gradually  raised  so  as  to  relieve  the 
disengaged  nitrogen  from  the  hydrostatic  pressure.  The  flask  is 
shaken  a  few  times,  and  when  tlie  reaction  is  completely  over  the 
a^jparatus  is  left  for  a  few  minutes  until  it  has  acquired  the  tem- 
perature of  tlie  room  in  which  the  experiment  is  performed.  An- 
other exact  levelling  of  the  measuring  tube  is  made  and  the  number 
of  the  division  corresponding  to  the  volume  of  the  developed  nitro- 
gen is  read  oif.  55  c.  c.  of  the  nitrogen  correspond  to  0.15  gramme 
of  urea,  so  that  a  single  division  corresjionds  to  .005  gramme  of 
urea.  If,  therefore,  we  use  5  c.  c.  of  urine,  each  measure  of  the 
nitrogen  evolved  will  correspond  to  0.1  per  cent,  of  urea  (or  0.44 
grain  per  fluidounce). 

Variations  occur  of  course  in  the  measured  gas  from  the  effect  of 
changes  in  the  temperature  and  barometric  pressure,  but  the  advo- 
cates of  this  method  allege  that  these  are  inconsiderable  in  ordinary 
clinical  work.  Other  nitrogenous  principles  are  also  included  with 
the  urea  in  the  estimation  by  this  method. 

Of  course  the  total  urine  passed  must  be  known  to  estimate  the 
total  amount  of  urea. 

COMPLAINTS  BY  PATIENTS  REGARDING  URINARY 
SYMPTOMS,  &G. 

Patients  sometimes  call  attention  to  alterations  in  the  ap- 
pearance of  their  urine,  of  which  it  is  important  to  be  able 
to  form  some  judgment.  In  the  section  on  the  "  Obvious 
Characteristics  of  Urine"  these  have  been  considered  (see 
p.  354). 

Frequency  and  pain  in  micturition  are  often  complained 
of  by  patients,  either  with  or  without  the  consciousness  of 
some  connection  between  these  symptoms  and  other  urinary 
disorders.  The  student  of  clinical  medicine  must  never 
forget  that  these  are  important  symptoms  of  surgical  as  well 
as  medical  diseases.  Frequency  of  micturition  may  be  due 
to  stricture  of  the  urethra,  and  it  is  very  common  in  elderly 
men  with  enlarged  prostate  ;  in  women  it  occurs  in  connec- 
tion with  uterine  irritation,  and  with  displacements  of  the 
womb.  Increased  frequency  in  micturition  may  be  due  simply 
to  irritability  of  the  urinary  organs,  but  it  is  also  often  of 
value  in  calling  attention  to,  or  marking  the  date  of,  an  in- 


UEINABY    SYMPTOMS.  395 

creased  secretion  of  urine,  as  in  diabetes,  and  in  certain  forms 
of  chronic  renal  disease.  In  the  early  stage  of  both  of  these, 
the  patient  may  find  that  he  has  begun  to  get  up  at  night  to 
pass  water,  and  although  he  may  attribute  this  to  his  being 
thirsty  and  to  his  drinking  more  water  than  usual,  the  thirst 
and  the  increased  urine  may  be  due  to  the  same  cause.  Fre- 
quency and  pain  in  micturition  often  occur  in  nephritis, 
s'trangury,  cystitis,  and  also  from  calculus  in  the  kidney, 
ureter,  or  bladder.  Scalding  or  pain  in  making  water  is 
often  complained  of  in  the  febrile  state ;  this  is  associated 
with  the  secretion  of  a  highly  acid  and  concentrated  urine  ; 
it  is  also  often  due  to  gritty  matter  (gravel)  in  the  urine,  and 
to  irritation  of  the  urethra  from  gonorrho3a.  In  women  it  is 
not  unfrequently  due  to  small  vascular  growths  at  the  orifice 
of  the  meatus  urinarius,  and  occasionally  to  prolapsus  of  the 
urethra  itself:  these  are  very  apt  to  escape  attention,  as  their 
situation  makes  it  a  matter  of  much  delicacy  to  examine  the 
parts  thoroughly.  In  male  children  the  pain  in  micturition 
may  be  due  to  the  irritation  of  a  phymosis.  Fissure  of  the 
anus,  and  other  affections  of  the  rectum,  or  disease  in  its 
neighborhood,  often  give  rise  to  pain  in  passing  water.  These 
various  causes  may  have  to  be  considered  and  decided  on  by 
an  ocular,  or  surgical,  or  instrumental  examination  of  the 
meatus,  the  urethra,  the  bladder,  the  womb,  or  the  rectum, 
JVot  unfrequently  the  presence  of  blood  in  the  urine,  its  color 
and  the  manner  of  its  coming,  whether  diffused  in  the  urine 
or  appearing  as  a  few  drops  at  the  end  of  micturition,  may 
assist  the  diagnosis.  The  presence  of  pus  likewise  in  the 
urine,  and  the  character  and  situation  of  the  pain,  are  of 
great  value  in  the  study  of  such  cases  (see  blood  and  pus,  pp. 
367  and  370).  Any  supposed  cause  of  the  painful  attack, 
such  as  injuries,  or  special  exertions  from  riding,  jolting,  &c., 
should  be  carefully  inquired  into.  (See  also  the  section  on 
Paralysis  of  the  Bladder,  p.  178.) 


396 


CHAPTER  XIV. 

SYMPTOMS   CONNECTED   WTIH   THE    MALE 
GENERATIVE  ORGANS. 

Disturbances  of  the  generative  organs  in  the  male 
come,  for  the  most  part,  under  the  notice  of  surgeons  ;  but 
complaints  are  sometimes  made  to  physicians  also,  concern- 
ing impaired  or  disordered  functions  in  these  parts,  and 
various  nervous  diseases  arise  from  sexual  excesses  and 
abuses.  Tlie  chief  complaints  met  with  in  medical  practice 
are  connected  with  impotence,  seminal  discharges,  and  mas- 
turbation. 

Impotence  supervenes  in  the  course  of  paralysis,  and  is 
very  common  in  those  forms  of  spinal  paralysis  which  involve 
the  bladder  and  rectum.  Its  occurrence  in  such  cases  is  not 
due  directly  to  sexual  excesses,  even  although  the  paralysis 
may  have  been  brought  on  in  this  way.  Premature  impo- 
tence, however,  apart  from  other  paralysis,  is  apt  to  arise 
at  a  comparatively  early  age  in  those  who  have  erred  in  this 
respect.  In  locomotor  ataxy  there  is  sometimes  an  impair- 
ment of  this  function,  although  it  has  been  alleged  that  this 
disease  differs  from  other  forms  of  spinal  paralysis  in  this 
respect,  and  that  there  may  be  even  an  excessive  aptitude 
for  frequent  indulgence.  (Trousseau.)  This,  however,  seems 
to  have  been  overstated.  Locomotor  ataxy  is  well  known 
to  depend  not  unfrequently  on  sexual  excesses  in  the  case  of 
men. 

Various  debilitating  diseases,  diabetes  for  example,  are 
characterized  by  impotence  as  part,  a[)parently,  of  the  general 
debility.  This  is  much  less  marked  in  some  other  exhaust- 
ing diseases,  and  especially  in  phthisis. 

Impotence  is  sometimes  imagined  or  dreaded  by  patients 
without  there  being  any  good  grounds  for  the  opinion  ;  and 
the  idea  sometimes  seizes  possession  of  the  mind  in  such  a 
form  as  to  constitute  a  species  of  insanity.  Prolonged  brood- 
ing on  such  subjects,  and  the  reading  of  quackish,  or  even 
of  legitimate,  medical  dissertations  on  the  consequences  of 
masturbation,  &c.,  are  apt  in  certain  minds  to  foster  the  de- 


DISORDERS    OF    GEXITAL    ORGANS    IN    MALE.      397 

lusion  and  to  upset  the  calmness  of  reason.  If  the^organs 
seem  sound  on  examination,  and  if  there  continue  to  be  in- 
dications of  functional  activity  in  them,  we  can  usually 
reassure  our  patients.  Points  of  importance  in  the  charac- 
ter of  the  impotence,  such  as  the  following,  have  sometimes 
to  be  determined  in  view  of  the  treatment :  The  absence  of 
sexual  desire:  more  or  less  antesthesia  of  the  glans  penis: 
imperfection  or  weakness  in  the  erection,  from  defect  in  the 
muscles  concerned,  or  from  other  causes:  premature  emis- 
sion. 

Priapism  (excessive  or  permanent  erection)  is  an  occa- 
sional symptom  in  spinal  paralysis  (myelitis  espccialh),  but 
no  indications  of  special  value  can  be  drawn  from  its 
presence. 

Masturbation  is  credited  with  the  production  of  an  untold 
number  of  ills,  both  bodily  and  mental.  Although  the  prac- 
tice is  highly  pernicious,  it  is  probable  that  its  influence  has 
been  overstated,  especially  in  connection  with  the  causation 
of  insanity,  although,  no  doubt,  it  sometimes  tends  to  men- 
tal disorder  (see  p.  230).  The  possibility  of  excessive,  or 
incontrollable  masturbation,  like  excessive  drunkenness, 
being  due  to  the  insane  tendency  of  the  patient,  must  be 
borne  in  mind.  The  frequent  practice  of  masturbation,  how- 
ever, may  produce  various  nervous  diseases,  just  as  we  find 
that  excessive  sexual  indulgence,  even  in  the  married  state, 
may  do  so ;  and  the  great  frequency  of  the  opportunities 
presented  to  the  masturbator  in  gratifying  his  desire,  ac- 
counts probably  for  part  of  the  special  evils  which  arise  in 
his  case.  Excess  in  venery  which  is  often  carried  to  an  ex- 
treme by  certain  newly  married  people,  and  sometimes  con- 
tiiLued  by  them  to  an  unreasonable  extent,  may  give  rise  to 
palpitations,  debility,  and  nervousness  of  various  kinds: 
among  the  more  serious  forms  of  disorder,  due  to  the  various 
forms  of  excess,  may  be  named  spinal  paralysis,  locomotor 
ataxy,  and  convulsions.  Mental  disorder  is  supposed  to 
arise  at  times  from  this  cause  (see  p.  230). 

It  should  be  remembered,  in  presence  of  anomalous  nervous 
sjTnptoms,  tliat  even  very  young  children  sometimes  prac- 
tise masturbation,  and  this  may  arise  from  some  mechanical 
irritation  in  the  parts,  or  from  less  obvious  causes  (such  as 
diabetes)  connected  with  the  organs. 

Seminal  discharges  may  likewise  be  greatly  exago-erated 
in  importance  by  the  pernicious  influence  of  quack  literature, 
or  the  reading  of  other  medical  books.  The  terrors  held 
34 


398      DISORDERS    OF    GENITAL    ORGANS    IN    MALE. 

over  their  patients  by  quacks  have  likewise  a  powerful  in- 
fluence on  many  persons.  A  certain  frequency  of  these 
emissions  is  natural  to  young  men  Avho  lead  a  chaste  life, 
and  their  frequency  is  often  increased  by  studious  or  seden- 
tary habits,  and  the  attendant  dyspepsia  and  constipation  so 
common  in  such  persons.  A  course  of  prurient  reading  also 
favors  this  unnatural  fi'equency.  When  the  emissions  occur 
every  night,  or  twice  or  thrice  a  week,  the  condition  is  cer- 
tainly unnatural,  although  not  necessarily  alarming,  and  this 
is  the  more  certain  if  the  discharges  occur  without  the  pa- 
tient being  aware  of  their  coming  away,  or  if  they  occur 
during  the  day,  or  without  any  previous  erection.  Patients 
sometimes  complain  very  much  of  this  symptom,  and  allege 
the  frequent  passing  of  semen  in  their  urine.  This  does 
occur  at  times,  but  the  milkiness  or  turbidity  complained  of 
is  not  unfrequently  due  merely  to  phosphatic  deposits  oc- 
curring in  the  alkaline  urine  within  the  bladder.  Chemical 
and  microscopic  tests  can  set  such  doubts  at  rest.  Another 
form  of  discharge  complained  of  consists  of  a  little  clear 
glairy  fluid,  like  white  of  egg,  frequently  or  constantly 
exuding  from  the  urethra.  This  is  due  to  prostatic  or  some 
other  than  the  seminal  secretion,  and  has  not  much  signifi- 
cance, although  it  is  increased  by  the  same  influences  which 
favor  frequent  seminal  emissions.  When  from  the  account 
given,  or  from  the  frequent  or  habitual  presence  of  sperma- 
tozoa in  the  urine,  we  are  satisfied  of  the  existence  of  a 
morbid  condition,  we  must  inquire  whether  any  unnatural 
excitation  of  the  parts  has  been  caused  by  masturbation,  a 
practice  which  patients  do  not  always  readily  confess.  The 
general  health  and  habits,  the  state  of  the  stomach  and 
bowels,  and  the  use  of  stimulating  food  or  drink  late  at  night 
must  be  inquired  into. 

This  condition  is  often  found  to  be  associated  with  a  most 
distressed  state  of  mind,  want  of  energy,  depression  of  spirits, 
with  perhaps  actual  weakness  and  incapacity  for  work ;  the 
patients  seem  often  to  foster  the  idea  of  their  dreadful  condi- 
tion, and  refuse  all  hope  and  consolation.  This  state  is  often 
associated  with  other  abnormalities,  particularly  frequent 
alkalinity  of  the  urine,  and  the  deposit  of  oxalates,  with  a 
high  specific  gravity  of  the  urine. 


399 


CHAPTER  XV. 

DISORDERS  OF  THE  FEMALE  ORGANS,  AND  THEIR 
RELATIONS  TO  THE  GENERAL  HEALTH.' 

MENSTRUATION  AND  ITS  DISORDERS. 

Mode  of  conducting  the  inquiries Students  often  expe- 
rience considerable  difficulty  sit  first,  in  conducting  inquiries 
on  these  subjects.  What  are  the  points  regarding  which 
information  is  to  be  elicited  ?  How  are  the  questions  to  be 
put  ?  The  inquiry  can  always  be  conducted  with  such  re- 
finement as  will  not  offend  any  proper  delicacy  of  feeling; 
whilst  on  the  other  hand  an  unfavorable  impression  may 
readily  be  conveyed  to  tlie  mind  of  the  patient  by  the  form 
or  mode  of  putting  a  question.  Coarseness  or  impertinence 
have  often  been  ascribed  to  medical  men,  simply  froiaa  want 
of  tact,  discretion,  or  personal  refinement  in  this  respect. 

In  many  cases  a  few  general  questions  are  all  that  is 
necessary.  In  hospital  practice,  where  the  cases  are  fully 
recorded,  inquiries  should  always  be  made  as  to  these  func- 
tions ;  but  in  private  practice  it  is  well  to  abstain  unless 
there  is  a  clear  necessity.  When  the  patients  are  young, 
inquiries  should,  when  possible,  be  made  through  the  parents  ; 
at  all  events  the  subject  should  be  introduced  through  them. 

It  is  well  to  lead  up  to  the  subject,  or  introduce  it  with 
special  bearing  regarding  the  symptoms  complained  of.  Thus 
one  question  may  introduce  another.  Having  asked  if  .the 
bowels  are  "  regular,"  there  may  next  come,  "And  are  you 

'  The  following  writers  naay  be  referred  to  for  further  information 
on  the  subjects  dealt  with  in  this  chapter  :  West,  Barnes,  Graily 
Hewitt,  Matthews  Duncan,  and  Sir  James  Simpson.  Montgomery 
on  the  Symptoms  and  Signs  of  Pregnancy,  Bernutz  and  Gouj)il's 
Clinical  Memoirs,  translated  l)y  the  New  Sydenham  Society,  and 
Lectiires  by  Hildebrandt,  Olshausen,  and  Gusserow,  in  the-German 
Clinical  Lectures  issued  by  the  same  Society  (vols.  Ixvi.  and  Ixxi.), 
may  be  consulted  with  advantage.  The  subject  must  also  be 
considered  in  connection  with  the  Physical  Examination  of  the 
Abdomen,  see  Chapter  xvi.,  Part  3,  and  some  of  the  works  referred 
to  there. 


400  DISORDERS    or    THE    FEMALE    ORGANS. 

regular  in  your  own  health  ?"  "  Not  too  often  or  too  mucli 
at  a  time  ?"  Or  if  some  special  pain  or  derangement  of 
function  is  complained  of,  the  subject  may  be  introduced  by 
asking,  "  Do  you  suifer  in  this  way  more  at  tlie  times  you 
are  unwell  than  between  times  ?" — and  tlien  follow  the  above 
questions.  It  is  well  even  at  times  to  otter  some  such  ex- 
planation as  "  symptoms  such  as  you  have  are  often  depend- 
ent upon  derangement  of  your  own  health."  Women  do  not 
understand  the  term  "  menstruation."  They  speak  of  being 
"unwell" — of  being  "regular."  It  is  also  known  by  some 
as  the  "  periods,"  or  the  "  courses."  They  will  also  say, 
"  My  own  has  left  me." 

Normal  Menstruation The  functional   activity   of   the 

female  generative  organs  is  normally  manifested  by  the 
periodic  discharge  of  blood,  which  constitutes  what  is  termed 
menstruation.  The  points  regarding  which  inquiry  is  to  be 
made,  or  in  other  words,  the  evidence  by  which  the  healthy 
performance  of  the  function  is  to  be  determined,  are:  (1) 
The  regularity  of  the  return  ;  (2)  the  duration  of  the  period; 
(3)  the  quantity  of  the  discharge ;  and  (4)  the  amount  of 
local  or  general  disturbance  which  accompanies  it.  There 
is  a  normal  standard  which  is  taken  as  the  guide,  but  each 
case  must  also  be  judged  by  the  individual  habit. 

(1)  The  interval  between  the  first  clay  of  menstruation 
and  its  reappearance  at  the  next  period  is  generally  reckoned 
as  twenty-eight  days  or  four  weeks,  but  certain  ditterences 
exist.  Some  women  "  alter"  by  the  calandar  rather  than 
the  lunar  month  ;  some  regularly  every  three  weeks,  w'hilst 
otliers  exceed  the  four :  and  even  a  degree  of  irregularity 
may  be  natural  to  the  individual  and  consistent  with  good 
health.  (2)  The  duration  of  the  discharge  likewise  varies, 
from  two,  or  even  one  day,  to  eight  days.  (3)  Some  lose 
but- little  blood,  others  a  considerable  quantity.  (4)  Some 
suffer  no  inconvenience,  whilst  others  have  considerable  local 
pain.  The  individual  habit,  therefore,  must  always  be  as- 
certained and  taken  as  tlie  criterion  of  healthy  function 
rather  than  a  general  standard.  What  in  one  person  may 
be  normal  may  in  another  be  evidenfe  of  excess  or  defect. 

It  is  not  sufficient  to  receive  a  simple  affirmative  reply  to 
the  question,  "Are  you  quite  regular?"  Many  women  will 
so  answer  when  afterwards  they  will  be  found  to  have  excess 
either  in  time  or  in  quantity,  or  in  both.  It  is  necessary, 
therefore,  to  follow  up  by  "  Not  oftener  than  you  used  to  be, 
not  more  at  a  time  than  you  always  had?" 


PRIMITIVE    AMENORRHCEA.  401 

Menstrutition  is  generally  accompanied  with  move  or  less 
malaise,  and  a  degree  of  local  discomfort  or  even  pain.  With 
every  derangement  of  function  an  increase  of  suffering  is 
present ;  but  the  relative  value  of  pain  will  be  discussed  in  a 
future  paragraph.  The  mucous  membrane  and  glands  of  the 
genital  tract  secrete  a  fluid  sufficient  to  keep  the  opposing 
surfaces  moist,  but  under  ordinary  circumstances  it  is  not 
manifest  externally.  In  unhealthy  conditions  it  escapes  ex- 
ternally, constituting  what  is  termed  leucorrhoea  or  popularly 
"  the  whites."  A  physiological  degree  of  leucorrhoea  is  often 
present  just  before  or  after  menstruation,  and  must  not 
be  confounded  with  the  pathological  state  when  persistent 
throughout. 

Varioiis  derangements  of  menstruation  have  received  dis- 
tinct terms  in  medical  nosology.  Its  non-appearance  at  the 
usual  age,  or  its  suppression  after  its  establishment,  is  known 
as  Amexorrh(jEA  ,  when  accompanied  by  excessive  pain  it  is 
termed  Dys:\iexorrhcea  ;  when  in  excess,  Menorrhagia, 
It  cannot,  however,  be  too  firmly  impressed  upon  the  mind 
that  these  terms  represent  symptoms  only,  and  not  actual 
diseases ;  and  however  useful  for  the  purpose  of  study  or 
description  the  divisions  may  be,  they  do  not  represent  any 
actual  state  which  will  determine  treatment.  Amenorrho3a 
may  in  one  case  be  the  result  of  bad  health,  and  in  another 
may  be  consistent  with  a  robust  constitution.  Menstruation 
may  regularly  recur,  and  yet  the  constitution  may  be  steadily 
becoming  undermined  from  the  strain  thrown  upon  it  in  the 
developmental  processes  which  are  taking  place.  It  must 
always  be  remembered  that  menstruation  is  but  part  of  the 
general  process  of  the  development  of  reproductive  life,  and 
that  the  latter  is  not  completed  when  the  menstrual  discharge 
has  once  regularly  been  established,  but  continues  for  some 
years  ;  in  fact  it  may  be  considered  .incomplete  in  many  cases 
until  the  twenty-second  year.  Whatever,  therefore,  the 
nature  of  the  prominent  symptom  may  be,  the  opinion  to  be 
formed  and  the  treatment  will  be  determined  less  by  that 
symptom,  than  by  the  constitutional  character  or  habit  of 
body  of  the  patient,  and  the  nature  of  the  disturbance  of  the 
general  functions. 

Primitive  Amenorrhoea  (Emansio  mensium),  where  the 
flow  has  never  taken  place.  The  inquiries  should  be  made 
to  elucidate  the  following  points  : — 

(1)  The  age  and  general  development.  In  this  country 
menstruation  first  shows  itself  from  the  thirteenth  to  the  fif- 

34* 


402     DISORDERS  OF  THE  FEMALE  ORGANS. 

teenth  year.  But  age  is  not  a  sure  criterion,  tlie  general 
development  of  the  body  must  be  associated  with  it.  (2) 
The  previous  history:  a  severe  illness  about  the  age  of 
puberty  may  retard  menstruation.  (3)  Is  the  ancmorrhoea 
part  of  impaired  health  ?  (anaemia,  chlorosis,  the  tubercular 
diathesis).  (4)  The  configuration  being  womanly,  and  tlie 
health  otherwise  good,  is  there  defective  development  of  the 
uterus,  or  defective  formation  of  the  generative  organs  ?  (ab- 
sence of  ovaries,  or  uterus,  or  vagina).  The  diagnosis  in  tlie 
latter  case  can  only  be  absolutely  made  by  a  physical  exami- 
nation— a  recourse,  however,  only  to  be  had  under  very 
special  circumstances. 

Internal  evidence  of  functional  activity,  without  discharge, 
is  sometimes  present  in  the  periodical  recurrence  of  lumbar 
and  pelvic  pains,  malaise,  headaches — symptoms  known  as 
the  menstrual  molimen.  At  times  epistaxis  or  other  hemor- 
rhages may  occur.  The  regular  periodicity  is  the  all-im- 
portant character,  of  such  symptoms.  They  are  evidence  of 
ovarian  activity,  and  the  presence  of  these  organs  is  all  that 
can  be  inferred  from  them.  The  absence  of  such  symptoms, 
however,  is  no  evidence  of  w^ant  of  these  organs.  The  oc- 
currence of  these  symptoms  with  increasing  severity,  and  the 
appearance  of  a  tumor  rising  out  of  the  pelvis,  is  diagnostic 
of  retained  secretion  (imperforate  hymen  or  occlusion  of  os, 
&c.).  In  all  cases  where  the  menstrual  molimen  has  occur- 
red, the  abdomen  should  be  examined  for  such  a  tumor. 

Menstruation  having  appeared,  is  the  health  suffering 
from  the  strain  of  the  developmental  process  ? — Amenorrhcea 
usually  causes  much  anxiety  on  the  part  of  parents  for  the 
health  of  their  daughters,  but  when  once  menstruation  has 
occurred  it  is  thought  the  danger  is  passed.  We  have 
already  observed,  however,  that  the  strain  of  reproductive 
development  continues  for  some  years  after  this  event,  and 
the  healtli  may  suffer  from  this  cause,  especially  under  the 
influence  of  bodily  or  mental  overwork.  The  symptoms  are 
very  varied,  and  often  indefinite,  and  may  affect  the  nervous 
or  digestive  systems,  or  the  blood-makiiig  function.  The 
important  point  is  to  determine  the  relationship  between  the 
constitutional  suffering  and  the  performance  of  the  uterine 
function.  In  one  class  the  faulty  nature  of  the  latter  is  the 
effect  of  the  former,  as  when  amenorrhcea  occurs  in  the 
course  of  phthisis  or  from  sedentary  habits.  There  is 
another  class,  however,  where  the  menstrual  tax  is  the  cause, 
the  general  suffering  the  effect.     In  the  latter  class  inquiries 


MENORRHAGIA.  403 

"W'ill  generally  elicit  that  at  first  the  lassitude  and  inaptitude 
for  work,  change  of  disposition  and  headaches,  or  the  de- 
rangements of  the  alimentary  canal,  or  the  localized  pains, 
were  part  of  the  menstrual  molimen,  but  that  by  the  accu- 
mulation of  effects  they  have  become  constant.  In  the  first 
class,  although  the  deranged  uterine  function  may  be  the 
immediate  cause  for  seeking  advice,  it  can  generally  be 
found  that  failure  of  the  general  health  in  some  respects  was 
antecedent,  although  unnoticed  at  the  time  ;  or,  at  all  events 
there  is  not  the  same  close  relationship  in  the  order  of  events. 
To  arrive  at  a  just  estimate  of  a  case  it  is  thus  highly  impor- 
tant to  determine  the  order  or  sequence  of  the  symptoms. 
Anaemia  may  be  caused  by  uterine  derangement,  or  the 
anffimia  may  be  the  cause  of  the  latter.  In  many  cases  it 
may  be  very  difficult  to  determine  the  relation,  but  success 
in  treatment  will  none  the  less  depend  upon  the  accuracy  of 
the  diagnosis. 

The  health  may  thus  suffer  with  perfect  regularity  in  the 
performance  of  menstruation.  Frequently,  ho\Vever,  this 
function  is  also  deranged.  The  character  of  the  derange- 
ment depends  to  a  large  extent  upon  the  constitutional  tem- 
perament. In  the  relaxed  or  strumous  habit,  there  is  gene- 
rally excess  in  frequency  or  amount,  with  copious  leucorrhoea; 
in  others,  the  tendency  is  to  scanty  or  irregular  menstruation  ; 
and  in  the  highly  nervous  temperament,  or  Avhere  there  is 
a  hereditary  histoiy  of  gout,  the  ovarian  pains,  spinal  irrita- 
tion, or  cerebral  suffering  predominate. 

Suppression  of  Menstruation  or  Secondary  Amenorrhoea. 
-^The  inquiries  should  be  guided  by  the  following  list  of 
causes : — 

(1)  Pregnancy  (see  signs  of  pregnancy,  p.  412.)  (2) 
Influences  affecting  the  system  at  a  catamenial  period  ;  (cold, 
mental  emotions,  and  exanthematous  diseases.)  (3)  Con- 
stitutional causes  ;  (after  fevers,  sedentary  and  confined  occu- 
pations, change  of  residence,  long  continued  mental  anxiety, 
aniemia,  chlorosis,  continued  drain  on  the  system,  tubercu- 
losis.) (4)  Local  causes  ;  (pelvic  inflammations,  stricture 
of  the  OS,  imperfect  involution  after  abortions  or  delivery  at 
full  time ;  more  rarely  diseases  of  the  ovaries  and  displace- 
ments of  the  uterus.) 

Menorrhagia  is  excess  of  the  menstrual  flow.  Hemor- 
rhage from  the  uterus,  not  menstrual,  is  termed  "  Metror- 
rhagia ;"  but  it  is  difficult  at  times  to  determine  whether  the 
discharge  is  of  the  one  nature  or  the  other.     The  distinction 


404     DISORDERS  OF  THE  FEMALE  ORGANS. 

is  nevertheless  important.  The  first  point  to  determine  is 
the  character  of  the  excess,  compared  with  the  ordinary 
standard  and  the  individual  habit  before  referred  to.  The 
excess  may  be  in  quantity,  or  in  duration,  or  in  frequency 
of  return,  or  in  any  two  or  all  of  these  combined.  What- 
ever the  change,  maintenance  of  regular  periodicity,  both  in 
duration  and  the  return,  favors  the  idea  of  a  truly  menstrual 
nature,  as  distinguished  from  hemorrhage.  Excess  in  dura- 
tion is  easily  noted,  but  patients  are  sometimes  not  so  ob- 
servant as  to  determine  quantity.  If  clots  are  discharged  in 
any  quantity  or  size  it  is  evidence  of  excess  in  amount,  but 
small  shreddy  clots  discharged  during  micturition  are  com- 
mon. The  question  may  also  be  put,  "Do  you  find  you 
have  to  use  more  napkins  than  formerly?"  In  metrorrhagia 
the  discharge  may  take  the  form  of  flooding,  or  considerable 
gushes,  and  in  female  parlance  it  may  be  described  as  "find- 
ing a  napkin  frequently  of  very  little  use." 

The  special  cause  of  the  menorrhagia  must  be  determined 
by  the  previous  history,  the  general  constitutional  condition, 
and  the  local  examination.  (1)  The  previous  history. 
Menorrhagia  is  frequent  after  abortions,  or  on  return  of  the 
catamenia  after  nursing,  especially  when  lactation  has  been 
prolonged.  It  is  common  shortly  after  marriage  ;  at  times 
menstruation  Avill  then  be  suppressed  for  one  or  two  periods 
and  return  in  excess — the  first  time  being  supposed  to  be  a 
miscarriage.  Change  of  residence  or  mode  of  life  is  at  times 
the  cause.  Profuse  menstruation  sometimes  follows  acute 
fevers  and  pelvic  inflammatory  affections.  (2)  The  general 
condition.  In  young  girls,  especially  those  of  the  strumous, 
or  so-called  phlegmatic  temperament,  menorrhagia  is  often 
present.  Also  at  all  periods  of  life,  from  a  sluggish  abdo- 
men ;  constipation,  hepatic  derangement,  loaded  urine,  a  full 
plethoric  habit  of  body,  or  rheumatic  or  gouty  constitutions 
are  frequently  associated  with  the  affection.  Altered  condi- 
tions of  the  blood,  associated  with  Bright's  disease,  purpura, 
and  the  like,  give  rise  to  menorrhagia  ;  but  in  simple  anaemia 
it  was  necessary  to  determine  by  the  history  whether  the 
an£Bmia  is  the  cause  or  the  effect.  (3)  Local  examination. 
It  is  often  a  question  Avhether  in  a  given  case  a  local  exami- 
nation is  necessary  or  not.  If  the  periodicity  is  well  main- 
tained, a  sufficient  constitutional  cause  having  been  found, 
and  no  other  marked  symptom  of  uterine  disease  existing, 
then  it  is  not  necessary  at  first.  But  if  treatment  has  already 
failed,  if  the  periodicity  is  not  well  observed,  and  if  there 


DYSMENORRHffiA.  405 

has  been  marked  flooding  or  metrorrhagia  rather  than  me- 
norrhagia,  and  if  any  other  symptoms  suggestive  of  organic 
clianges  or  of  displacement  are  present,  then  an  examination 
should  be  insisted  upon. 

Dysmenorrhcea A  certain  degree  of  pain  and  discomfort 

is  felt  during  a  menstrual  period  by  the  majority  of  women, 
but  at  times  it  becomes  so  severe  as  to  compel  them  to  seek 
advice.  Cases  of  this  description  are  usually  divided,  in 
systematic  works,  into  congestive,  neuralgic,  and  mechanical 
dysmenorrhcea.  The  division  is  not  a  very  practical  one, 
for  in  many  cases  all  the  forms  are  more  or  less  combined. 
There  are  also  some  authors  who  view  all  cases  as  primarily 
mechanical  in  origin.  Into  the  discussion  of  this  subject  we 
cannot  here  enter,  but  must  view  it  from  the  purely  clinical 
aspect. 

The  first  question  is,  has  the  dysmenorrhcea  existed  from 
the  earliest  years  of  menstruation  ?  If  so,  it  is  often  asso- 
ciated with  an  imperfect  development  of  the  uterus.  In 
such,  the  flow  is  scanty,  irregular  in  recurrence,  or  coming 
and  going  during  the  period.  If  regular,  the  cjuantity  natu- 
ral, and  the  pain  present  from  the  first,  the  presumption  is 
that  there  is  some  defect  in  formation  (narrow  os,  with  small 
cervix)  or  congenital  malposition  ;  and  the  further  evidence 
of  obstruction  will  also  be  present.  In  this  class  of  cases,  it 
must,  however,  be  remembered  that  menstruation  may  for 
two  or  three  years  be  comparatively  easy,  but  when  the 
quantity  is  increased,  or  the  character  is  changed  from  con- 
stitutional causes,  or  the  sensibility  of  the  nervous  system 
increases  by  the  accumulation  of  effects,  the  dysmenorrhcjea 
may  come  on  later  and  more  gradually.  The  fact,  there- 
fore, of  its  non-existence  in  the  earlier  years  does  not  exclude 
a  congenital  mechanical  cause  of  the  dysmenorrhcea. 

The  severity  of  the  pain  diflTers  as  to  time :  it  may  be  felt 
before  the  discharge,  or  only  with  its  appearance;  it  may 
last  for  a  few  hours  only,  or  be  felt  during  the  whole  period ; 
it  may  be  steady  and  continuous,  or  paroxysmal  and  remit- 
ting. It  varies  in  its  position,  central  in  the  uterus,  or 
general  in  the  pelvis,  or  lateral  in  one  or  both  ovaries.  It 
may  be  a  hot  throbbing  pain,  or  acute  and  lancinating,  and 
running  in  the  course  of  certain  nerves.  It  is  nearly  always 
reflected  to  the  back,  and  often  to  the  head  or  under  a  breast, 
limited  there  to  a  small  spot.  These  characters  must  be 
noted  and  taken  as  factors  in  arriving  at  an  opinion. 

"When  the  pain  is  chiefly  due  to  obstruction  to  the  flow,  it 


406  DISORDERS    OF    THE    FEMALE    GROANS. 

will  probably  be  paroxysmal  in  character,  each  attack  being 
followed  by  a  flow — and  at  first  the  discharge  is  dark  in 
color,  sometimes  black  and  tarry.  The  obstruction,  how- 
ever, is  not  necessarily  a  constriction  of  the  canal.  It  may 
be  from  dysmenorrhocal  casts — the  mucous  membrane  being 
shed  in  pieces — or  it  may  arise  in  a  purely  congestive  form, 
and  be  owing  to  the  rapid  escape  of  the  blood,  permitting 
partial  coagulation.  In  such  a  form  it  will  most  likely  last 
only  during  the  first  day.  This  latter  character  is  more  or 
less  common  to  the  purely  congestive  forms,  the  discharge 
giving  relief  to  the  vessels,  but  it  will  be  variable  in  degree 
according  to  the  amount  of  the  congestion,  the  permanency 
of  its  cause,  and  the  amount  of  the  discharge.  By  some 
authors  the  arrest  of  the  pain  after  the  first  day  is  regarded  as 
evidence  of  a  flexion  in  the  cervix, — the  congestion  of  the 
organ  producing  erection  of  the  uterus,  and  straightening  of 
the  canal. 

The  localization  of  the  pain  to  one  or  both  iliac  regions  or 
to  one  or  more  nerves,  together  with  disturbance  of  the  ner- 
vous system  generally,  will  determine  how  far  the  case  is  one 
of  purely  neuralgic  character.  But  it  must  always  be  borne 
in  mind  that  neuralgias  are  frequently  due  to  mechanical 
causes,  or  have  their  origin  in  disease  of  the  cervix.  They 
may  likewise  have  their  origin  in  general  constitutional 
conditions,  specially  hereditary  gout. 

By  vaginal  examination  the  existence  of  a  mechanical 
cause  of  dysmenorrhoea  is  recognized  by  narrowness  of  the 
cervical  canal — usually  associated  with  a  small,  or  elongated, 
or  conical  cervix — and  also  when  marked  fiexions  of  the 
uterus  are  detected. 

"  The  Chaxge  of  Life  :"  The  Climacteric  Period, 
THE  Menopause.  By  these  terms  are  denoted  the  end  of 
reproductive  life  in  the  female,  as  indicated  by  the  cessation 
of  menstruation.  This  period  is  mark(!d  by  a  predisposition 
to  both  local  and  general  derangements  of  health.  It  occurs 
between  the  fortieth  and  fiftieth  years. 

Local  Derangements The  manner   of  the  cessation  of 

menstruation  varies.  It  may  cease  suddenly  or  gradually — ■ 
the  intervals  becoming  longer  and  more  iri-egular,  and  the 
quantity  variable.  Tliis  period  of  irregularity  is  spoken  of 
as  "the  dodging  time."  Frequently  the  change  is  indicated 
by  excess  of  menstruation,  both  in  quantity  and  frequency. 
The  menorrhagia  of  this  period  should  not  be  overlooked, 
but  carefully  investigated,  especially  if  continuing  past  the 


LEUCORRHOEA.  4:01 

ordinary  age.  Hemorrhage  returning  after  a  lengthened  in- 
terval, and  presenting  no  definite  periodicity,  is  always 
suspicious  and  calls  for  an  examination. 

General  Derangements — The  nervous,  vascular,  and  di- 
gestive systems  frequently  suffer.  One  of  the  most  frequent 
complaints  consists  in  flushings,  chiefly  of  the  head  and  face, 
and  sometimes  felt  over  the  whole  hody.  It  is  associated 
with  a  hot,  bursting  feeling  in  the  skin,  and  is  often  relieved 
by  perspiration.  A  dryness  of  the  skin,  or  want  of  ordinary 
perspiration,  is  frequently  associated  with  the  flushings.  A 
peculiar  headache  affecting  the  occipital  region,  and  extend- 
ing to  the  neck,  is  often  experienced.  It  has  long  been  rec- 
ognized that  there  is  at  this  age  a  special  predisposition  to 
mental  derangements.  Rheumatic  and  gouty  affections  may 
also  manifest  tliemselves,  although  previously  absent.  The 
digestive  system  tends  to  become  sluggish  and  impaired. 

CLINICAL  VALUE  OF  SPECIAL  PELVIC  SYMPTOMS. 

Leucorrhcea We  have  already  referred  to  the  physio- 
logical variety  of  "  the  whites."  It  is  common  either  before 
or  after  menstruation,  and  lasts  but  a  limited  time.  A  con- 
siderable amount  of  "the  whites"  is  met  with  at  times 
during  pregnancy. 

In  young  girls  leucorrhcea  is  common,  and  is  often  regarded 
as  the  cause  of  the  weakness.  It  is  properly  the  effect,  and 
may  be  met  with  in  debilitated  constitutions,  especially  the 
strumous  and  phthisical.  The  absence  of  any  other  uterine 
symptom  except  amenorrhoea,  or  scanty  and  irregular  secre- 
tion, will  point  to  the  truly  constitutional  nature.  Any  bad 
hygienic  influences,  and  certain  occupations,  such  as  the  use 
of  the  sewing  machine,  may  lead  to  this  form  of  the  affection. 

Leucorrhcea  is  an  almost  constant  attendant  of  all  uterine 
affections,  but  usually  other  symptoms  are  associated  there- 
with. In  such  cases  a  careful  examination  should  be  made 
when  possible,  before  treating  in  routine  fashion  the  promi- 
nent symptom. 

The  secretion  may  come  from  the  uterus,  the  vagina,  or 
from  both.  In  the  former  case  it  may  be  seen  by  means  of 
the  speculum  escaping  from  the  os,  clear  and  glairy,  like  the 
white  of  ego^  becoming  thick  and  opaque  in  the  vagina. 
Curdy  pieces  or  thick  tenacious  mucus  generally  indicate 
that  the  cervix  is  the  seat  of  origin.  The  microscope  will 
also  detect  the  source  by  the  cliaracter  of  the  epitlielial  cells 


408  DISORDERS    OF    THE    FEMALE    ORGANS. 

— round  or  columnar  from  tlie  uterine  cavity,  and  tesselated 
from  the  vagina.  The  discharge  may  be  purulent  in  cha- 
racter, but  no  special  inference  can  be  derived  from  this  con- 
dition. The  diagnosis  must  be  based  on  other  considerations. 
A  mucous  discharge  may  be  present,  and  even  abundant, 
Avithout  the  patient  being  conscious  of  it,  either  from  inatten- 
tion or  from  its  escaping  only  during  micturition. 

Children  at  all  ages  are  liable  to  a  form  of  leucorrhoea, 
which  however  is  situated  in  the  vulva  only.  It  is  often  very 
obstinate,  and  is  dependent  upon  a  depraved  constitutional 
state,  associated  at  times  with  local  causes,  such  as  want  of 
cleanliness,  or  the  irritation  of  diarrhoea  or  worms. 

Water)/  discharges.  Associated  with  leucorrhoea  or  occur- 
ring alone,  the  discharge  is' often  watery  in  character,  some- 
times greenish  in  color,  at  others  pink  or  tinged  with  blood. 
If  thei'e  is  any  cause  for  suspecting  pregnancy,  it  may  be  the 
rare  affection  termed  hydrorrJtcea  gravidarum,  or  a  symptom 
of  the  cystic  (hydatidiibrm)  degeneration  of  the  ovum.  A 
greenish  watery  discharge  sometimes  follows  parturition,  and 
is  associated  with  imperfect  involution  of  the  uterus.  Met 
Avith  under  other  circumstances,  and  specially  when  pink  or 
frequentl)^  bloody,  the  usual  cause  is  malignant  disease.  In 
all  cases  the  odor  is  sufficient  to  distinguish  between  a  watery 
discharge  and  an  involuntary  escape  of  the  urine.  Several 
cases  are  on  record  where  watery  discharges  formed  the  sole 
symptom  of  a  uterine  polypus,  but  these  are  more  commonly 
associated  with  liemorrhages. 

Pain. — The  significance  of  tliis  symptom,  apart  fi'om  the 
revelations  of  a  local  examination,  must  be  determined  by 
the  character,  the  exact  seat,  and  the  time  of  recurrence  or 
exacerbation,  with  the  apparent  cause. 

(1)  The  character  is  very  variable,  dull  and  constant, 
sliarp,  shooting,  hot,  throbbing,  &c.  One  term  frequently 
used  is  "  down  bearing  ;"  as  used  in  general  it  is  utterly  in- 
definite. It  is  employed  for  the  feeling  of  fulness  or  disten- 
sion ;  or  it  may  be  simply  weight,  or  the  sensation  that  some- 
thing is  trying  to  press  out  at  the  "  front  passage."  It  is 
met  with  not  only  in  uterine  affections,  but  also  when  the 
bladder  alone  is  irritable,  or  it  may  arise  from  hemorrhoids. 

(2)  The  exact  seat  of  the  pain  must  be  noted — whether 
limited  to  a  spot  or  diffused  over  a  limited  area.  Thus  pain 
is  often  described  as  in  the  side — this  may  be  near  the  crest 
of  the  ilium  or  in  the  inguinal  region.  Again,  a  j^ain  in  the 
latter  part  may  be  genei'al  or  indefinite,  as  when  due  to  dis- 


PELVIC    PAIN.  409 

ease  of  the  cervix — but  when  arising  from  the  ovary,  the 
spot  can  be  exactly  localized  and  covered  with  two  fingers. 
By  careful  localization  affections  of  special  nerves  can  be 
made  out.  The  pain  of  cancer  of  the  uterus  is  frequently 
localized,  immediately  behind  the  pubes,  gnawing  or  grinding 
in  character,  marked  by  nocturnal  exacerbations.  Pain  with 
a  marked  periodic  character  of  this  description  may  warrant 
the  assumption  of  malignant  disease  of  the  fundus  {vide  Sir 
J.  Y.  Simpson's  works) ;  at  the  same  time  periodic  nocturnal 
pains  are  sometimes  present  in  acute  pelvic  inflammations. 
Dorsal,  lumbar,  and  sacral  pains  have  no  special  pathogno- 
monic significance — they  are  common  to  all  pelvic  affections. 

(3)  An  important  question  to  determine  is  whether  pain 
is  menstrual  in  origin.  If  recurring  only  with  the  catamenia., 
lasting  for  a  short  time  after,  and  disappearing  till  the  next 
period,  the  question  is  simple  enough.  But  a  pain  may  be 
constant  and  yet  menstrual.  In  such  a  case  the  history  will 
show  that  at  first  the  pain  occurred  only  with  menstruation, 
but  gradually  increasing  (by  accumulation  of  effects)  it  has 
become  permanent,  though  still  subject  to  exacerbations  at  a 
monthly  period. 

(4)  Lastly,  light  may  be  thrown  on  the  nature  of  the 
pain  by  the  conditions  which  set  it  up,  or  cause  relief  or 
aggravation.  Is  it  affected  by  position  ?  Pains  of  an  in- 
flammatory nature,  or  due  to  malposition,  are  relieved  by 
rest  and  aggravated  by  the  erect  position.  Neuralgic  pains 
are  not  so  infiuenced.  The  weary  backache,  induced  by 
exercise  or  fatigue,  and  relieved  by  rest,  is  often  due  to  the 
accumulated  effect  of  the  menstrual  pain.  Again,  pain 
occurring  when  one  position  is  assumed  for  a  time,  but  re- 
lieved by  a  change  of  position,  or  by  walking  about,  would 
point  to  blood  stasis — being  due  to  temporary  distension  of 
the  vessels  of  the  part.  A  pain  which  is  easy  while  walking 
but  comes  on  while  sitting  is  often  of  this  nature. 

Is  the  pain  affected  by  movement  ?  An  inflammatory 
condition  is  always  so.  If  slight  it  may  be  elicited  only  by 
a  jolt  or  sudden  movement.  Neuralgic  pains  are  not  so  in- 
fluenced. If  muscular,  it  may  only  arise  on  movement  of 
certain  muscles.  It  must  be  remembered  that  muscular 
action  produces  pressure,  and  may  elicit  a  neighboring  in- 
flammatory pain,  as  in  the  action  of  the  psoas  muscle  in  the 
various  positions  of  the  leg. 

The  pain  may  be  associated  with  the  act  of  micturition  or 
defecation.  In  pelvic  peritonitis  acute  pain  on  micturition 
35 


410  DISORDERS    OF    THE    FEMALE    ORGANS. 

is  frequent,  but  there  is  other  pain  as  well.  If  closely 
limited  in  its  relation,  occurring  with  the  act  and  lasting  for 
some  tiine  after,  the  cause  is  most  likely  to  be  in  tlie  bladder 
or  urethra  ([)ainful  caruncle).  Intermitting  pains  of  short 
duration,  simulating  tlie  pains  of  labor,  are  met  with  where 
something  is  being  expelled  from  the  uterus — such  as  a  blood 
clot,  retained  mucous  secretion,  or  dysmenorrha^al  membrane. 
The    Coxstitutioxal,    or    Remote    Dekaxgemexts 

DUE  TO  Pelvic  Affectioxs From  the  endless  variety 

of  these  it  is  evident  that  only  a  few  can  be  here  enumerated, 
such  as  every  student  should  be  aware  of. 

1.  The  digestive  system — Want  of  appetite,  sickness, 
and  nausea  are  frequent.  The  uterine  origin  is  indicated  if 
the  sickness  occurs  on  assuming  the  erect  posture  in  tlie 
morning,  or  with  exacerbations  at  the  menstrual  period,  or 
if  the  general  symptoms  show  remissions  with  the  pelvic 
symptoms.  Constipation  is  more  frequently  a  cause  or 
source  of  aggravation  of  pelvic  disorder  than  the  effect,  ex- 
cept where  pain  on  defecation  incites  the  patient  to  restrain 
the  action.  The  same  may  be  said  of  sluggishness  of  the 
liver,  associated  with  high-colored  or  sedimentary  urine. 

2.  The  nervous  and  vascular  systems A  pain  limited  to 

a  spot  under  the  breast  is  a  frequent  complaint ;  also  pains 
in  the  back  in  the  lumbar  region,  or  even  extending  between 
the  shoulders — often  sensitive  to  the  touch.  Tic  may  like- 
wise have  a  uterine  origin,  but  in  such  cases  it  will  fre- 
quently have  a  clear  association  with  the  catamenial  period  ; 
it  occurs  also  with  pregnancy.  The  headaches  are  not  al- 
ways definite  in  character,  tliey  may  be  frontal,  or  occipital, 
or  at  the  vertex.  At  the  change  of  life  the  occiput  is  the 
more  general  seat  (see  Change  of  Life,  p.  406).  Through 
the  nervous  system,  the  heart  and  bloodvessels  are  frequently 
affected — palpitation,  flushings,  and  the  like.  A  very  com- 
mon effect,  due  to  pelvic  derangement,  is  coldness  of  the 
extremities,  which  again  reacts  in  aggravating  the  pelvic 
pains.  Epileptic  attacks  may  occur  regularly  with  the  men- 
strual periods.  Spinal  irritation  has  sometimes  a  uterine 
origin,  as  also  hysteria  and  other  mental  derangements. 

3.  As  a  very  special  influence  due  to  pelvic  origin  must 
be  noted  the  faintings  and  constant  feelings  of  exhaustion,  or 
loss  of  energy,  experienced  by  many  suffering  from  even 
slight  uterine  ailments.  In  some  patients  the  influence  ex- 
erted through  the  pelvic  nerves  is  very  marked.  Many 
patients  are  exhausted  and  feel  faint  after  each   time  the 


CONSTITUTIONAL    DERANGEMENTS.  411 

bowels  are  moved.  An  injection  will  often  cause  great  pros- 
tration. In  tiie  same  manner  inflammation  of  the  cervix, 
though  causing  no  pain  but  only  a  constant  discharge,  will 
frequently  produce  great  lassitude  and  ready  fatigue. 
Haemorrhoids  frequently  have  a  similar  effect.  Retro-version 
and  ante-version  of  the  uterus  act  in  a  similar  manner,  even 
when  there  is  no  local  tenderness.  The  patient's  expression 
frequently  is  that  all  enei'gy  or  strengtli  seems  to  go  as  soon 
as  she  gets  up  and  begins  to  move  about.  Tonics  are  useless 
in  such  cases,  so  long  as  the  local  condition  is  nnalleviated. 
The  special  pelvic  symptoms  may  be  very  slight,  at  other 
times  they  are  severe  and  well  marked.  The  grouping  of 
symptoms  in  such  cases  generally  is  as  follows  :  Some  pelvic 
suflering,  gradually  loss  of  strength  and  appetite,  ready  ex- 
haustion, with  sickness  on  assuming  the  erect  position,  and 
steady  loss  of  flesii  from  inability  to  take  nourishment. 

The  determination  of  the  relation  between  pelvic  derange- 

vients  and  remote  or  constitutional  suffering Affections  of 

the  pelvic  organs  are  known  to  produce  marked  disturbances 
in  the  function  of  remote  organs ;  and  again,  derangements 
of  otlier  parts  frequently  produce  changes  in  the  uterine 
function;  It  is  therefore  highly  important  to  decide  the  re- 
lationship. Tiie  question  has  been  frequently  referred  to  in 
previous  sections.  In  many  cases  it  is  evident  enough. 
Thus,  amenorrhoea  in  a  phthisical  patient  may  be  regarded 
as  a  common  effect,  not  the  cause,  of  the  general  affection. 
When  not  so  clear,  tlie  order  and  succession  of  the  symptoms 
must  be  carefully  investigated. 

When  derangements  of  the  stomach  are  of  pelvic  origin, 
there  are  some  special  characters  which  may  indicate  the 
association — as  when  they  partake  of  the  characters  met  with 
in  pregnancy — as  sickness,  chiefly  on  assuming  the  erect 
position  in  the  morning  (when  dependent  upon  disease  of  the 
cervix  this  is  often  noted)  ;  or  if  manifesting  recurrence  or 
exacerbations  at  menstrual  periods ;  or  if  coming  and  going 
with  special  pelvic  symptoms.  The  same  holds  good  with 
many  neuralgic  affections.  Frequently,  however,  it  may  be 
found  that  whilst  due  to  pelvic  irritation  the  derangement 
has  become  permanent  and  persists,  whilst  the  exciting  cause 
is  intermittent,  or  may  even  have  passed  off  altogether.  The 
"  weary  backache"  is  often  of  this  nature  due  to  menstrual 
irritation,  yet  persistent.  The  early  history,  however,  will 
reveal  the  true  nature. 


412  DISORDERS    OF    THE    FEMALE    ORGANS. 


THE  DIAGNOSIS  OF  PREGNANCY. 

Pregnsincy,  it  must  be  remembered,  may  occur  under  cir- 
cumstances where  it  might  not  be  expected,  as  in  very  young 
girls,  or  in  women  past  the  ordinary  age  of  cliild-bearing. 
Pregnancy  has  been  recorded  in  this  country  at  the  thirteenth 
year,  and  as  late  as  the  fifty-fourth.  Women  who  have 
stopped  having  children  for  many  years  may  again  begin  to 
bear  when  nearing  the  change  of  life ;  or  a  woman  may  be 
pregnant  for  the  first  time  after  many  years  of  married  life. 
It  is  very  common  for  mothers  who  are  nursing  to  be  again 
pregnant  without  menstruating,  or  even  being  aware  of  it. 
Again,  a  patient  may  have  had  amenorrhcea  for  many  months, 
or  have  always  been  very  irregidar,  and  yet  become  preg- 
nant. Caution,  therefore,  is  ever  needful,  and  more  espe- 
cially in  the  use  of  the  uterine  sound  as  a  means  of  diagnosis. 

In  the  latter  half  of  pregnancy,  whan  the  uterine  tumor  is 
perceptible  above  the  pubes,  when  either  the  foetal  move- 
ments may  be  felt,  or  the  auscultatory  signs  can  be  heard, 
and  when,  in  first  pregnancies,  the  mammary  signs  are  dis- 
tinct, there  can  be  little  difficulty  in  the  diagnosis ;  errors 
are  then  made  by  careless  examination.  The  sup])ression  of 
menstruation  with  the  occurrence  of  ;!.n  al)dominal  tumor 
should  always  necessitate,  in  the  medical  practitioner's  mind, 
the  exclusion  of  pregnancy,  by  the  positive  evidence  of  a 
thorough  examination. 

In  the  earlier  months  the  diagnosis  is  more  difficult,  and 
in  doubtful  cases  it  should  be  deferred.  The  suspicion, 
though  felt,  should  only  be  expressed  on  positive  evidence. 
The  sudden  arrest  of  menstruation,  without  apparent  cause, 
in  a  woman  who  has  always  been  previously  regular — asso- 
ciated with  morning  sickness,  and  shooting  pains  or  fulness 
in  the  breasts — is  often  quite  sufficient  presumptive  evidence 
of  pregnancy. 

Suppression  of  the  Catamenia,  although  one  of  the  first 
symptoms,  is  equivocal  in  value.  It  merely  opens  up  the 
question.  The  suppression  may  be  due  to  otlier  causes.  It 
is  possible  also  for  a  woman  to  menstruate  once  or  twice 
after  concej)tion  :  in  such  cases  the  amount  of  discharge  is 
markedly  diminished.  A  discharge  of  blood  may  also  occur 
during  pregnancy,  and  be  repeated  at  intervals,  without  being 
menstrual  in  its  nature. 

Morning  sickness  alone  is  of  little  value,  it  is  variable  in 


SIGNS    OF    PREGNANCY.  413 

its  occurrence  as  to  time  mid  duration,  is  often   absent,  and 
may  arise  from  otlier  condirions. 

Changes  in  the  Mammce.  The  breasts  early  sympathize 
with  the  condition  of  the  uterus,  but  they  do  so  in  otlier  con- 
ditions as  well  as  in  pregnancy.  They  increase  in  size,  and 
become  sensitive  with  shooting  pains.  It  is  in  first  pregnan- 
cies that  the  areolar  signs  are  of  most  value,  but  even  then 
they  vary  greatly  in  different  individuals ;  and  a  deepening 
of  the  color,  with  slight  prominence  of  the  nipple,  may  ai'ise 
from  other  conditions  of  the  generative  organs.  It  is  in  the 
third  month  that  the  increased  turgescence  begins  to  alter 
the  characters.  The  nipple  becomes  more  prominent,  the 
areola  increases  in  size,  and  its  color  deepens,  whilst  the  folli- 
cles on  its  surface  become  more  prominent.  As  pregnancy 
advances  these  changes  are  more  pronounced,  and  the  surface 
assumes  a  moistened  appearance.  After  tlie  fifth  month  there 
may  appear  Avhat  has  been  described  by  Montgomery  as  the 
secondary  areola,  immediately  around  the  other,  faint  in 
degree,  as  if  the  color  had  been  washed  out. 

The  abdominal  tumor.  The  abdomen  is  often  perceptibly 
enlarged  before  the  uterine  tumor  can  be  felt  externally. 
After  the  twelfth  week,  sometimes  earlier,  the  uterus  can  be 
defined  above  the  pubes,  by  the  sixteenth  it  should  reach 
midway  between  the  pubes  and  umbilicus,  and  by  the  twen- 
tieth be  as  high  as  the  latter  point.  It  is  not  always  central 
in  position,  most  frequently  there  is  an  inclination  to  the 
right.  Its  uniform  spheroidal  shape,  and  moderately  firm 
elastic  resistance,  are  of  service  in  distinguishing  between  it 
and  other  tumors,  differing  in  these  respects  from  the  hard 
fibroid,  or  more  distinctly  fluctuating  ovarian  cyst.  Should 
the  consistence  change  under  manipulation,  the  tumor  be- 
coming firmer,  it  is  almost  certain  to  be  uterine,  though  not 
necessarily  pregnancy.  At  times  the  uterus  may  be  so  lax 
before  the  seventh  month  that  there  may  be  some  difficulty 
in  defining  the  tumor,  especially  if  the  abdomen  be  full  or 
tense.     Mistakes  are  frequently  made  from  this  cause. 

Vaginal  examination.  The  cervix  is  at  first  displaced 
downwards,  afterwards  somewhat  backwards,  the  enlarged 
body  being  felt  in  front  (anteversion).  At  times  the  dis- 
placement of  the  body  is  backwards.  The  cervix  from  an 
early  period  undergoes  softening  of  its  tissues,  beginnino-  in 
the  mucous  coat,  and  gradually  invading  all  the  tissues,  till 
towards  the  end  of  pregnancy  the  cervix  seems  shortened. 
The  vaginal  portion  is  really  shorter,  from  the  uterus  being 

b5*  ■ 


414:     DISORDERS  or  THE  FEMALE  ORGANS. 

held  high  up,  but  the  cervical  caual  is  not  diminished  in  length 
till  a  few  days  before  parturition.  In  pluriparje  the  os  in 
the  later  months  is  sutRciently  patent  to  admit  the  point  of 
the  finger.  The  vaginal  mucous  membrane  early  assumes  a 
deep  violet  hue. 

Fatal  movements.  By  the  mother  these  are  usually  felt, 
for  the  first  time,  from  the  sixteenth  to  the  eighteenth  week  ; 
this  is  spoken  of  as  •' quickening."  Somewhat  later  they 
may  be  felt  by  the  examining  hand,  and  about  the  same  time 
haUotement  may  also  be  made  out.  Women  who  are  not 
pregnant,  but  have  a  strong  desire  to  have  children,  or  are 
suffering  from  mental  ailments,  frequently  imagine  that  they 
feel  the  movements  of  a  child. 

Auscultatory  signs.  The  uterine  souffle  may  be  heard 
earlier  than  the  fo?tal  heart's  sounds,  but  it  is  not  certainly 
diagnostic  of  pregnancy;  it  is  heard  at  times  in  fibroid  tu- 
mors. The  usual  time  for  the  pulsations  of  the  heart  is  the 
eighteenth  week,  but  they  have  been  detected  earlier.  In 
listening  for  them  before  the  seventh  month,  a  point  in  the 
mesial  line  somewhere  between  the  pubes  and  umbilicus,  but 
nearer  the  former,  is  where  the  sounds  are  most  likely  to  be 
heard.  After  the  seventh  month  they  will  be  found  most 
frequently  about  the  middle  point  in  a  line  from  the  umbilicus 
to  the  superior  spine  of  the  ilium  on  the  right  side  or  the 
left.  But  the  place  must  necessarily  vary  with  the  position 
of  the  child.  The  rate  varies  from  130  to  160,  and  the  beats 
are  of  course  not  synchronous  with  the  maternal  pulse. 

PELVIC  EXAMINATIONS. 

Indications    for    a   physical   examination   of  the  pelvic 

organs It  may  be  laid  down  as  a  general  principle,  in  the 

words  of  Dr.  Bai'nes,  "  That  when  constitutional  or  remote 
effects  are  present,  associated  with  marked  symptoms  of  de- 
rangement of  function  of  the  pelvic  organs,  the  necessity  of 
exploring  the  physical  state  of  these  is  as  clear,  as  is  that  of 
examining  the  state  of  tlie  heart  or  lungs,  when  these  organs 
perform  their  functions  with  distress,  and  the  whole  system 
suffers."  At  the  same  time,  for  obvious  reasons,  such  a 
course  is  only  to  be  adopted  under  special  necessities.  In 
many  cases  a  diagnosis  can  be  arrived  at  without  this.  It 
is  unnecessary  to  subject  a  patient  to  this  ordeal  when  tlie 
local  derangements  are  clearly  but  part  of  a  general  consti- 
tutional suffering,  especially  when  the  local  symptoms  are 


PELVIC    EXAMIXATIOXS.  415 

but  functional,  and  are  unassociated  icith  local  distress. 
To  this  class  belong  many  cases  of  amenorrhoea  and  menor- 
rhagia.  (For  rules  as  to  examination  in  the  latter  case  see 
p.  404.)  In  amenorrhcca  marked  periodic  local  suffering 
calls  for  an  external  examination  at  least,  in  order  to  detect 
any  tumor  from  retention  of  the  menstrual  fluid. 

It  is  the  nature  and  amount  of  the  local  suffering  that 
must  determine  the  necessity  for  an  examination,  together 
with  the  order  or  succession  of  the  symptoms.  There  are 
cases,  however,  where  from  the  presence  of  an  apparently 
sufficient  constitutional  cause,  and  the  local  symptoms  being 
slight  in  degree,  an  error  in  diagnosis  may  be  made  from 
want  of  an  examination.  Thus,  after  delivery  an  imper- 
fect convalescence  may  have  occurred ;  much  weakness  and 
faintings  are  complained  of;  the  patient  is  nursing,  and  to 
this  cause  the  debility  is  assigned.  If  under  such  circum- 
stances, any,  though  slight,  local  symptoms  are  present,  such 
as  pain,  or  continued  discharge,  a  careful  vaginal  examina- 
tion should  be  made,  and  a  slight  parametritis  or  sub-involu- 
tion may  be  detected.  At  the  change  of  life  also,  local 
affections,  which  demand  attention,  are  liable  to  be  over- 
looked, from  the  tendency  to  regard  the  uterine  derangement 
as  due  simply  to  •■  the  change."  If  the  local  affections  are 
severe,  or  persistent,  a  vaginal  examination  should  always 
be  made. 

Mode  of  conducting  pelvic  examinations — The  patient 
should  lie  upon  her  left  side,  with  her  shoulders  low,  and 
thrown  as  much  forward  on  the  front  of  the  chest  as  possible, 
and  her  knees  drawn  up.  The  forefinger  of  the  right  hand, 
well  oiled,  is  to  be  introduced  between  the  labia  from  behind 
forwards  ;  the  opening  of  the  vagina  being  reached,  the 
finger  should  be  gently  pressed  into  the  canal  following  its 
direction.  Note  in  this  procedure  the  sensitiveness  of  the 
parts,  and  the  consistence  of  the  tissues.  The  perineal  and 
vaginal  constrictors  will  contract  slightly,  but  will  soon 
again  relax,  when  the  finger  can  be  introduced  to  the  full 
extent.     The  following  points  must  then  be  noted  : — 

1.  The  presence  of  tenderness  or  pain  upon  pressure  by 
the  finger,  care  being  taken  to  note  the  exact  situation  of 
the  tenderness. 

2.  The  position  and  the  direction  of  the  cervix. — The 
vaginal  portion  of  this  can  always  be  reached.  The  os 
should  be  felt  at  the  end  of  the  finger,  and  the  direction  ot 
the  cervix  should  be  downwards  and  backwards.     To  esti- 


416     DISORDERS  OF  THE  FEMALE  ORGANS. 

mate  its  position  in  the  pelvis,  there  are  two  fixed  points  for 
reference.  First,  the  symphysis  pnbis ;  the  point  of  the 
finger  resting  against  the  cervix  in  the  anterior  cul-de-sac, 
the  part  of  the  finger  which  rests  against  the  lower  margin 
of  the  bones  indicates  the  distance.  This  point  should  be 
slightly  beyond  the  second  joint.  If  the  os  is  beyond  reach, 
or  nearer  the  os  pubis  than  above  indicated,  there  is  some 
displacement.  The  posterior  cid-de-sac  should  only  be 
reached  by  pressing  back  the  perineum.  The  second  point 
of  reference  is  the  coccyx — feeling  for  it  externally,  the  dis- 
tance of  it  from  the  os  should  be  noted.  The  latter  is  fre- 
quently placed  too  high  in  the  diagrams  in  our  text  books. 
In  those  who  have  not  borne  children  it  is  seldom  more  than 
an  inch  above  the  coccyx,  but  in  those  who  have  had  a 
family  it  is  often  within  half  an  inch,  and  frequently  lies 
anterior  to  the  coccyx. 

3.  The  shape  and  consistence  of  the  cervix  with  the  de- 
gree of  patency  of  the  os. 

4.  The  mobility  of  the  cervix — Experience  is  required  to 
estimate  this  correctly;  in  general  it  may  be  stated  that  it 
should  be  mobile  to  the  extent  of  a  quarter  of  an  inch  in  any 
direction.  Fixedness  of  the  uterus  is  an  important  diagnos- 
tic point. 

5.  The  feeling  of  resistance  of  the  vaginal  walls Apart 

from  the  cervix  there  should  be  no  fulness  or  resistance.  In 
the  normal  position  a  portion  of  the  body  of  the  uterus  may 
be  felt  through  the  superior  wall.  Feces  in  the  rectum  will 
give  resistance  in  the  posterior.  Otherwise  any  degree  of 
fulness  on  one  side,  as  compared  with  the  other,  or  of  hard- 
ness, must  be  noted. 

6.  The  examination  is  not  complete  without  combining 
the  use  of  both  hands,  the  one  internal,  the  other  external, 
pressing  dow'nwards  into  the  pelvis  from  above  the  pubes. 
In  this  manner  the  size  and  position  of  the  uterus  or  the  size 
and  relations  of  a  tumor  may  be  determined. 

7.  By  the  sound  and  speculum  w^e  complete  the  examina- 
tion (see  pp.  420,  422).  The  sound  enables  us  to  determine 
the  direction  in  which  the  uterus  lies  and  the  length  of  its 
cavity.  It  enables  us  also  to  a  certain  extent  to  decide  as  to 
the  relation  which  exists  between  the  uterus  and  any  pelvic 
or  abdominal  tumors.  It  should  never  be  used  if  there  is  a 
suspicion  of  pregnancy,  and  only  by  experienced  hands  if 
there   is  marked  tenderness  either  in  or  near  the  uterus. 


VAGINAL    EXAMINATIOjST.  417 

Much  mischief  may  be  done  by  the  incautious  use  of  this 
instrument. 

By  the  speculum  we  bring  the  cervix,  os,  and  vagina  un- 
der the  observation  of  the  eye.  Experience  diminishes  to  a 
large  extent  the  necessity  for  its  use  in  many  cases.  It  need 
not  be  employed  by  any  if  the  cervix  feels  normal  in  shape 
and  consistence,  and  if  there  is  no  leucorrhoea.  When  dis- 
charge is  present  it  may  be  necessary  to  employ  it,  to  decide 
the  seat  of  origin — whether  uterine  or  not.  It  should  not  be 
employed  except  by  the  experienced  in  the  case  of  unmarried 
women. 

8.  Examination  per  rectum  is  often  of  advantage,  but  re- 
quires experience.  It  may  be  employed  when  exaniination 
per  vaginam  is  objectionable.  By  this  method  the  finger 
can  reach  higher  posteriorly;  and  it  is  believed  by  some  to 
give  increased  facilities  in  determining  the  condition  of  the 
ovaries.  The  uterus,  when  retroverted,  may  also  by  this 
means  be  brought  more  readily  under  the  command  of  com- 
bined internal  and  external  manipulation,  to  determine  its 
size. 

UlAGXOSTIC  VALUE  OF  EVIDENCE  OBTAIXED  BY  A  VAGI- 
NAL Examination: — 

1.  Increased  sensitiveness  oi-  pain  on  pressure, — («.)  At 
the  orifice  of  the  vagina,  Tlie  following  conditions  may 
give  rise  to  this  symptom:  .Small,  highly  vascular  and  sensi- 
tive points  in  the  mucous  membrane,  or  a  similar  general 
condition  around  the  orifice;  inflammation  of  the  vagina; 
fissure  of  the  vaginal  orifice.  These  conditions  are  associated 
with  a  strongly  spasmodic  condition  of  the  sphincter  vaginte, 
and  constitute  what  has  been  termed  "vaginismus."  The 
carunculte  myrtiformes  are  sometimes  highly  sensitive. 
Lastly,  the  conditions  may  arise  from  painful  caruncle  at  the 
orifice  of  the  urethra,  or  from  the  presence  of  piles.  (J>.) 
Tenderness  in  the  region  of  the  bladder,  when  that  organ  is 
inflamed,  (c.)  Tenderness  on  pressure  or  movement  of  the 
cervix — endocervicitis,  or  endometritis;  also,  when  the  ovary 
is  inflamed,  from  movement  or  pressure  being  conveyed  to 
it.  If  pelvic  peritonitis  is  present  the  cervix  is  often  fixed, 
but  pressure  will  elicit  pain.  (fZ.)  In  pelvic  peritonitis,  or 
cellulitis,  pressure  not  directed  on  tlie  uterus,  that  is,  to  one 
side  or  the  other,  will  cause  pain — whilst,  if  the  uterus  alone 
is  sensitive,  there  will  be  no  tenderness  if  the  uterus  be  not 
moved.  If  the  ovary  is  affected,  pain  is  elicited  by  pressure 
in  the  direction  of  the  organ  ;  the  further  diagnosis  is  de- 


418  DISORDERS    OF    THE    FEMALE    ORGANS. 

pendent  on  the  degree  of  fulness  or  the  form  of  the  swelling. 
(^.)  The  presence  of  ;i  limited  localized  inflammution  of  the 
connective  tissue  around  the  cervix  (parametritis  proper) 
may  often  be  ascertained  by  gentle  pressure  round  about  the 
cervix,  so  as  not  to  cause  movements  of  that  organ.  This 
will  elicit  pain ;  whereas  if  the  pressure  is  made  more  gen- 
eral, so  as  to  move  the  cervix,  the  seat  of  the  pain  may  be 
supposed  to  be  in  it,  when  it  is  only  at  the  side.  An  in- 
flamed state  of  Douglas's  pouch  may  thus  be  made  out  also. 
(/.)  The  tenderness  from  haemorrhoids  may  be  recognized 
by  directing  the  pressure  backwards. 

2.  Tlie  position  and  direction  of  the  cervix The  normal 

condition  has  already  been  described.  Version  or  even 
flexion  of  the  uterus  is  rarely  present  without  some  change 
in  the  position  and  direction  of  the  cervix.  The  diagnosis 
cannot  be  determined  by  this  point  alone,  but  it  is  a  material 
aid  in  guiding  the  judgment.  If  the  os  is  beyond  the  reach 
of  the  finger  and  looking  backwards,  probably  there  is  ante- 
version  ;  if  nearer  the  os  pubis  than  normal,  and  looking  for- 
wards, then  the  opposite  condition.  This  evidence,  however, 
must  always  be  associated  with  what  is  determined  as  to  the 
presence  and  position  of  increased  resistance,  or  the  feeling 
of  solidity  in  ditf'erent  directions,  with  the  form,  amount,  and 
fixedness  of  the  solid  body. 

3.  The  shape  and  consistence  of  the  cervix  ivith  the  degree 
of  patency  of  the  os. — (a.)  The  shape  of  the  cervix  is  some- 
times diagnostic.  If  small  and  nipple-shaped,  there  is  likely 
to  be  an  undeveloped  (infantile)  uterus.  A  somewhat  elon- 
gated and  conical  cervix  is  associated  with  constriction  of 
the  cervical  canal,  causing  marked  dysmenorrhoea.  A  small 
cervix,  flattened  in  its  superior  border,  with  the  os  eccentric, 
is  at  times  associated  with  congenital  anteflexion,  and  con- 
striction of  the  canal.  (6.)  The  normal  consistence  has  been 
likened,  not  inaptly,  to  that  of  the  point  of  the  nose.  In 
the  course  of  pregnancy  it  becomes  softened  and  relaxed. 
In  diseased  conditions,  it  frequently  becomes  soft  and  vel- 
vety, with  patency  of  the  os.  The  cervix  is  often  indurated 
(either  in  nodules  or  generally)  in  chronic  endocervicitis, 
and  in  malignant  disease.  It  is  also  subject  to  hypertrophic 
elongation  which  may  affect  either  one  or  both  lips,  (c.) 
The  shape  of  the  cervix  is  changed  in  those  who  have  borne 
children.  It  has  lost  its  circular  or  slightly  ovoid  character 
with  small  round  os ;  it  is  more  or  less  fissured,  oval,  and 
uus3^mmetrical ;  at  times  a  part  or  the  whole  of  one  lip  may 


SIGNIFICANCE    OF    PELVIC    EXAMINATIONS.      419 

be  lost.  In  the  atrophied  conclition  in  tlie  aged,  the  vaginal 
portion  may  be  entirely  removed,  the  vagina  seeming  to  end 
in  a  point.  The  changes  in  cancer  will  be  afterwards  de- 
scribed (see  p.  42G). 

4.  3Iohility  of  the  cervix  is  increased  when  there  is  pro- 
lapsus or  a  tendency  thereto.  It  is  diminished  or  absent  in 
pelvic  peritonitis  or  cellulitis,  and  in  malignant  disease. 

5.  T'he  sensation  imparted  to  the  finger  by  the  vaginal 
walls  may  be  variously  altered.  There  may  be  only  the 
feeling  of  fulness  of  one  side  as  compared  with  the  other. 
From  this  there  may  be  any  degree  of  undefined  resistance 
up  to  hardness  and  fixedness.  These  are  associated  with 
inflammatory  conditions,  and  are  rarely  without  tenderness 
on  pressure.  The  swelling  frequently  alters  the  position  of 
the  OS,  which  is  pushed  away  from  the  side  afifected.  If  the 
inci'eased  resistance  can  be  denned  in  shape,  having  a 
rounded  character,  its  nature  must  be  determined  by  its 
seat,  size,  consistence,  and  mobility,  whether  it  is  the  body 
of  the  uterus,  the  ovary,  something  occupying  Douglas's 
pouch,  or  a  calculus.  When  possible,  the  uterine  sound  is 
required  to  decide  the  diagnosis. 

When  the  position  of  the  uterus  is  normal  a  portion  of  its 
body  can  be  felt  through  the  anterior  Avail  of  the  vagina. 
In  anteversion  it  can  be  felt  more  readily  and  to  a  greater 
extent,  and  the  os  is  further  removed.  Inflammatory  pro- 
ducts (rare  in  this  situation)  are  not  so  well  defined  and  are 
less  mobile  than  the  uterus.  A  rounded  tumor  behind  the 
cervix  may  be  due  to  retroflexion,  or  to  fluid  or  solid  con- 
tents in  Douglas's  pouch ;  the  size  and  consistence  will 
sometimes  suffice  for  a  decision  ;  or  by  the  bi-manual  exam- 
ination, the  fundus  may  be  felt,  behind  the  os  pubis,  whilst 
the  tumor  is  still  in  situ  behind. 

The  solidity  of  some  forms  of  pelvic  cellulitis  cannot  be 
felt  by  the  finger  joer  vaginam  alone,  but  can  be  determined 
by  the  combined  internal  and  external  method. 

When  a  hard  tumor  can  be  felt  through  the  abdominal 
wall,  and  at  the  same  time  a  hard  fixed  resistance  through 
the  vagina,  it  must  not  be  inferred  that  there  really  is  a 
solid  tumor  of  the  apparent  size ;  such  a  condition  is  often 
produced  by  a  matting  together  of  the  intestines,  the  broad 
ligament,  and  the  Fallopian  tube.  The  inflammatory  hard- 
ening of  a  pelvic  cellulitis  will  sometimes  extend  upwards 
beneath  the  peritoneum  far  up  on  the  abdominal  wall.  The 
thin  cake-like  feeling  of  the  superior  edge  and  the  immo- 


420     DISORDERS  OF  THE  FEMALE  ORGANS. 

bility  of  the  wall  over  the  tumor,  will  readily  distinguish 
this  form. 

When  lateral  movements  (not  merely  downward  pressure) 
can  be  conveyed  from  an  abdominal  tumor  to  the  cervix 
uteri,  it  establishes  a  uterine  connection.  This  character  is 
of  importance  in  determining  between  uterine  and  ovarian 
tumors.  The  diagnosis  is  completed  by  the  use  of  the 
sound. 

The  Uterine  Sound  and  its  Diagnostic  Value — 
We  have  already  alluded  to  the  caution  necessary  in  the  use 
of  this  diagnostic  aid.  where  there  is  a  suspicion  of  preg- 
nancy, and  where  there  is  pelvic  inflammatory  mischief. 
The  sound  originally  proposed  by  vSir  .James  Simpson  is  the 
best. 

Mode  of  introduction The  instrument  should   be  held 

lightly  by  the  right  hand,  and  its  point  guided  to  the  os  by 
the  forefinger  of  the  left.  As  it  enters  the  cervix  the  stem 
will  be  near  the  under  surface  of  the  symphysis  pubis,  par- 
allel to  the  urethra.  In  the  normal  ]iosition  of  the  uterus 
the  direction  of  the  canal  is  forwards  and  upwards.  To 
cause  the  point  of  the  instrument  to  take  this  direction  the 
handle  must  be  drawn  backwards  towards  the  perineum. 
When  fully  introduced  it  sliould  rest  on  that  structure.  The 
distance  the  point  has  entered  is  recognized  by  the  finger  in 
the  vagina.  The  knob  or  swelling,  2-^  inches  from  the 
point,  which  indicates  the  normal  length  of  the  cavity, 
should  be  just  at  or  within  the  os.  Failure  to  introduce  it 
thus  far  is  often  due  to  not  tilting  tlie  handle  sufficiently 
back.  jSTo  force  must  be  used,  the  instrument  should  glide 
in.  If  resistance  is  met  with,  move  the  ])oint  about,  by 
making  the  sound  turn  on  the  forefinger  resting  on  the  point 
of  curvature.  Take  special  care  that  the  stem  is  not  made 
to  rotate  merely  on  its  fixed  extremity.  If  the  position  of 
the  uterus  is  abnormal,  the  direction  given  to  the  sound 
must  be  varied  according  to  the  information  obtained  by  the 
digital  examination,  or  the  sensation  derived  through  the 
instrument  itself.  In  retroversion  the  position  and  direction 
of  the  sound  will  be  the  reverse  of  that  described  as  the 
normal. 

Diagnostic  value 1.    Constriction  of  the  cervix  may  be 

recognized  if  the  lumen  be  too  small  to  permit  the  probe  to 
pass.  The  nan-owing  from  flexion  may  be  recognized  by 
the  seat  of  aiTest,  and  by  the  special  manoeuvre  necessary  to 


UTEEINE    SOUND.  421 

overcome  it,  such  as  tilting  in  a  certain  direction,  or  having 
to  press  the  fundus  upwards. 

2.  The  lenr/th  of  the  cavity. — The  normal  length  is  2^ 
inches.  It  will  be  found  elongated  in  (a)  recent  delivery, 
the  normal  size  is  not  reached  till  the  third  or  fourth  week. 
In  repeated  examinations  a  steadily  diminishing  length  of 
the  cavity  is  valuable  evidence  of  recent  parturition.  Under 
various  conditions  the  diminution  in  the  size  of  the  uterus  is 
arrested  (subinvolution) — after  delivery  at  the  full  time  and 
also  after  abortions.  Usually  in  this  condition  it  will  be 
found  S^  inches,  but  it  may  be  considerably  beyond  this. 
(b)  In  hypertrophy  from  chronic  congestion,  metritis,  and 
malignant  disease  of  the  body  (3j  inches).  (c)  From 
uterine  tumors.  The  amount  of  elongation  is  greatly  de- 
pendent upon  their  seat;  if  subperitoneal  the  increase  may 
be  slight ;  as  they  approach  the  mucous  surface  the  tendency 
is  to  lengthen  the  cavity.  A  tumor  of  the  fundus  may  give 
an  apparent  shortening,  (c?)  The  elongation  may  exist  in 
the  cervix  only,  or  in  its  vaginal  portion  from  hypertrophic 
elongation  of  both  lips.  It  may  thus  measure  4  to  5  inches, 
and  has  been  found  as  much  as  9  inches  (Huguier).  The 
portion  above  the  vagina  may  also  be  elongated  from  drag- 
ging of  the  uterus  upwards  by  tumors,  (e)  The  cavity  is 
SHORTENED  in  defective  development  (infantile  uterus)  ;  in 
inversion  of  the  uterus  ;  in  tumors  from  adhesions  ;  in  the 
atrophic  state  in  the  aged  ;  Sir  James  Simpson  described  a 
condition  of  hyper-involution,  where  the  normal  process  has 
been  in  excess. 

3.  Displacements  of  the  icterus. — These  are  readily  deter- 
mined by  the  direction  in  which  the  sound  passes. 

4.  To  ascertain  the  connection  or  non-connection  of  tumors 
xvith  the  uterus. — If  the  sound  passes  directly  into  the  tumor 
it  proves  it  to  be  uterine.  A  large  sub-involuted  uterus  may 
thus  be  distinguished  from  other  swellings.  A  swelling  be- 
hind the  cervix  may  thus  be  determined  to  be  the  fundus,  or 
something  occupying  Douglas's  pouch.  If  the  sound  does 
not  pass  directly  into  the  tumor  it  may  still  be  uterine,  or 
have  uterine  attachments.  The  point  is  to  be  decided  by 
moving  the  tumor,  and  observing  whether  motion  is  con- 
veyed or  not  to  the  sound  ;  or  vice  versa.  The  non-uterine 
nature  will  be  further  confirmed  if,  by  aid  of  the  sound,  the 
uterus  and  tumor  can  be  made  to  move  simultaneously  in 
different  directions.  In  this  manner  small  ovarian  tumors 
can  generally  be  differentiated. 

36 


422  DISORDERS    OF    THE    FEMALE    ORGAXS, 

0.  The  sound  is  further  of  service,  in  elevating  the  fundus 
or  drawing  it  forward,  so  as  to  bring  it  witliin  reach  of  the 
combined  internal  and  external  manipulation,  to  determine 
more  accurately  the  size  of  the  organ. 

The   Specllum Ferguson's  tubular  glass  speculum  is 

the  best  adapted  for  general  use.  Of  the  bivalve  form,  that 
known  as  Cusco's  is  now  most  preferred.  A  good  window 
light  is  the  best ;  this  should  be  on  a  level  with  the  bed. 
Where  the  light  is  bad  the  tubular  form  of  instruments  has 
a  decided  superiority  in  illuminating  power.  Should  artifi- 
cial light  be  necessary,  a  shade  should  be  devised  to  screen 
the  observer's  eyes,  or  a  mirror  may  be  used  for  reflecting 
the  light,  as  in  laryngoscopy. 

Tiie  lateral  position  of  the  patient  should,  if  possible,  be 
adopted.  It  is  less  tr^-ing  to  her,  and  sufficient  in  the  ma- 
jority of  cases.  At  times,  however,  with  Ferguson's  specu- 
lum, wemay  fail  to  gain  a  view  of  the  os  in  the  lateral  posi- 
tion, when  we  may  succeed  in  the  dorsal.  The  shoulders  of 
the  patient  must  be  on  a  higher  level  than  the  buttocks. 
The  dress  should  be  carefully  adjusted  so  as  not  to  expose 
any  part  of  the  thighs. 

Having  oiled  the  instrument,  and  holding  it  in  the  right 
hand,  we  gently  separate  the  labia  with  the  fingers  of  the 
left.  TTith  them  for  a  guide,  the  instrument  is  presented  at 
the  orifice  of  the  vagina ;  we  then  press  it  backwards  so  as  to 
depress  the  perineum,  and  with  a  slight  rotatory  action  in- 
troduce it  within  the  orifice.  The  direction  is  now  to  be 
changed,  backwards,  to  make  it  glide  over  the  perineum, 
not  upwards  towards  the  uterus.  When  once  fully  intro- 
duced, the  outward  end  should  be  depressed  well  on  the 
perireum.  and  if  the  cervix  does  not  present  properly  at  the 
inner  orifice,  its  position  may  be  altered  by  a  gentle  rotatory 
movement  of  the  speculum. 

When  the  bivalve  speculum  is  used,  care  must  be  taken 
that  it  is  introduced  fairly  behind  the  cervix  before  the 
blades  are  expanded.  The  opening  up  of  the  blades  must 
be  done  slowly  and  carefully,  watching  the  efl^ect  meanwliile. 

The  above  forms  are  those  of  general  use,  and  are  ser- 
viceable for  inspection,  or  when  topical  applications  to  the 
uterus  have  to  be  made.  When  any  surgical  procedure  is 
necessary,  the  "  duckbill,"  or  Sims'  speculum,  has  decided 
advantages.  It  necessitates  an  assistant  to  hold  it,  but  this 
drawback  has  been  overcome  by  various  modifications.  In 
using  it  the  position  of  the  patient  is  of  even  greater  impor- 


USES    OF    THE    SPECULUM.  423 

tance  than  in  the  other  forms.  For  its  successful  use  there 
must  come  into  pUiv  the  dih^tation  of  the  vagina  by  air, 
when  the  contents  of  tlie  abdomen  are  made  to  gravitate 
awaj  from  the  pelvis.  This  is  accomplished  bv  placing  the 
patient  in  the  semi-prone  position.  She  lies  on  the  left  side, 
the  arm  drawn  backwards  from  under  the  side  or  placed 
above  the  head,  the  shoulders  low,  and  the  patient  turned  as 
much  as  possible  in  this  position  to  lie  on  her  face  or  front 
of  the  shoulder.  In  this  position  when  the  speculum  is 
introduced,  so  that  the  convex  surface  presses  back  the 
perineum,  air  enters  the  vagina  and  distends  it.  The  in- 
strument is  then  introduced  to  the  full  extent  and  adjusted, 
so  as  to  bring  the  cervix  into  view,  and  the  handle  entrusted 
to  an  assistant. 

Uses   of  the  speculum  and  appearances  of  the  cervix 

By  the  above  means  a  full  view  of  the  os  uteri  and  vaginal 
portion  of  the  cervix  can  be  obtained.  The  mucous  mem- 
brane of  the  vagina  thi-oughout  its  whole  extent  can  also  be 
inspected.  This  is  best  done  in  the  withdrawal  of  the  tubu- 
lar instrument ;  the  condition  of  the  mucous  membrane  may 
be  seen  as  it  gradually  folds  in  behind  the  speculum  as  it  is 
withdrawn. 

The  cervix  should  present  a  smooth  surface  of  uniform 
color.  In  the  nuUiparoas,  it  is  regular  in  form,  with  circu- 
lar or  slightly  oval  os  ;  in  those  who  have  borne  children  it 
is  often  irregular  in  shape,  and  the  os  more  or  less  fissured. 
In  the  latter  case  the  use  of  the  speculum,  especially  the  bi- 
valve form,  tends  to  evert  the  lips  of  the  cervix,  and  thus 
bring  into  view  the  redder,  more  highly  injected  surface  of 
the  canal ;  and  this  is  liable  to  be  mistaken  for  inflammatory 
injection.  When  the  membrane  is  inflamed  this  eversion 
may  be  natural  and  not  produced  by  the  instrument.  Slightly 
withdrawing  or  closing  the  instrument  will  distinguish  be- 
tween the  two. 

In  catarrhal  conditions  of  the  cervical  canal,  the  vaginal 
portion  may  be  normal,  but  there  is  seen  escaping  from  the 
OS  a  clear  glairy  fluid,  like  white  of  egg.  This  becomes 
white  and  opaque  in  the  vagina. 

In  addition  to  the  angry-looking  eversion  of  the  lips,  we 
may  frequently  meet  with  n;d  patches  extending  to  the  vagi- 
nal surface,  or  isolated  patches  thereon.  These  are  produced 
by  injection  or  enlargement  of  the  papillae.  If  the  epithe- 
lium is  intact,  the  surface  is  smooth,  but  when  it  is  removed 
the  appearance  presented  is  velvety  or  granular,  and  the  mem- 


424  DISORDERS    OF    THE    FEMALE    ORGANS. 

brane  readily  blecils  to  the  touch.  Associated  with  this  con- 
dition the  cervix  is  frequently  swollen  and  enlarged.  Aph- 
thous eruptions  have  been  described,  and  more  rarely  small 
erosions  are  met  with.  Sypliilitic  ulcers,  similar  to  those 
found  on  the  glans  penis,  are  also  described. 

Small  mucous  polypi  and  cysts,  which  have  escaped  the 
cognizance  of  the  finger,  may  be  detected  by  the  eye.  They 
arise  from  changes  in  the  mucous  glands  within  the  canal. 
Minute  cysts  may  be  seen  in  the  immediate  neigldjorhood  of 
the  OS,  sometimes  encircling  it  (oviila  Nabothi)  ;  they  feel 
hard  and  pearly,  when  punctured  they  collapse. 

The  changes  in  the  cervix  due  to  malignant  disease  will 
be  described  under  that  head.  But  it  may  be  remarked  here 
that  when  the  disease  is  well  pronounced,  the  nature  can  be 
determined  by  digital  examination  alone,  and  the  use  of  the 
speculum  should  be  limited  to  aiding  the  topical  applications 
(see  p:  426). 

Pelvic  Ixflammatioxs Inflammation  may  invade  only 

the  peritoneum  (perimetritis),  or  the  cellular  tissue  of  pelvis 
(parametritis),  or  it  may  be  that  both  are  affected  together. 
AHhough  clearly  distinguishable  pathologically,  we  are  not 
yet  in  a  position  to  lay  down  definite  diagnostic  signs  between 
them.  Tumors  of  large  size,  dense,  firm  or  hard,  may  arise 
from  matting  together  of  the  broad  ligament  and  bowel ;  a 
thin  structure,  such  as  the  peritoneum  or  a  cyst  wall,  may, 
when  inflamed,  become  hard,  and  give  the  feeling  of  a  dense 
solid.     Hence  the  difficulty  in  diagnosis. 

Inflammation  may  exist  without  hardness  or  tumor.  From 
the  prominence  given  to  these  signs  in  the  descriptions  of 
pelvic  cellulitis,  many  affections  of  truly  inflammatory  nature 
are  frequently  ovei'looked.  Fulness  and  tenderness  on  one 
side  of  the  pelvis  may  be  the  only  signs  present  ;  just  as  the 
cheek  may  be  swollen  and  tender  from  toothache  without 
there  being  the  hardness  of  a  gum-boil.  The  cellular  tissue 
on  either  side  of  the  cervix  may  thus  be  acutely  sensitive  to 
the  touch  without  being  hard.  This  is  often  mistaken  for 
tenderness  of  the  uterus  itself,  but  it  may  be  readily  distin- 
guished by  pressure  upwards,  to  the  one  side,  insufficient  to 
move  the  uterus.  Gentle  pressure,  by  slight  flexion  of  the 
first  joint  of  the  finger,  is  the  best  means  to  determine  the 
exact  seat  of  the  affection  ;  movement  of  the  cervix  will 
elicit  pain  if  there  is  any  inflammatory  condition  near  it. 
With  tiie  tenderness  in  this  situation  careful  comparison  with 
the  opposite  side  will  generally  enable  one  to  detect  a  fulness 


PELVIC    INFLAMMATIONS.  425 

or  sense  of  increased  resistance,  corresponding  to  tke  seat  of 
pain.  This  condition  is  very  common,  especially  after  child- 
birth or  abortion,  and  also  with  endocervicitis;  but  the  ab-. 
sence  of  hardness  or  tumor  leads  frequently  to  an  oversight. 
A  distinct  hardness  in  this  region  is  occasionally  met  with, 
narrow  in  character  and  extending  laterally  from  the  uterus, 
corresponding  with,  and  limited  to,  the  base  of  the  broad  liga- 
ment, and  sometimes  existing  on  both  sides.  More  usually, 
however,  it  presents  a  form  to  be  presently  described. 

Fulness  and  tenderness  on  one  side  of  the  vagina,  not  in 
such  close  relation  to  the  cervix  as  in  the  former  case,  are 
met  with  from  ovarian  irritation  or  inflammation.  A  swol- 
len and  tender  ovary  may  be  defined  by  the  finger  through 
the  vaginal  wall.  In  an  early  condition  the  wall  is  movable 
over  it,  but  it  is  liable  to  become  fixed  in  the  general 
swelling. 

Hardness  and  fixation  are  generally  combined.  The 
hardness  may  be  limited  to  the  more  strictly  peri-uterine 
region,  displacing  and  partially  encircling  the  cervix,  and 
having  a  rounded  and  defined  margin.  At  other  times  the 
whole  of  one  side  of  the  pehis  feels  solid  without  any  de- 
fined margin  or  roundness.  The  latter  swellings  are  clearly 
cellulitic,  but  with  the  former  it  is  more  difficult  to  say 
whether  they  are  parametric  or  perimetric.  When  the 
tumor  can  be  felt  above  the  brim,  occupying  a  clearly  cen- 
tral position,  not  united  to  the  walls,  and  especially  if  par- 
tial movement  can  be  imparted  to  it,  the  probability  is  that 
it  is  peritonitic,  and  that  the  tumor  is  formed  by  the  mat- 
ting together  of  the  different  structures.  Such  tumors  when 
they  suppurate  do  not  open  externally. 

Parametric  tumors  rise  out  of  the  pelvis  in  connection 
with  the  walls,  extending  into  the  iliac  fossa,  forwards  on 
the  anterior  wall,  or  backwards  along  the  psoas  muscle. 
They  are  frequently  to  be  felt  above  Poupart's  ligament,  and 
even  extending  high  above  it ;  but  the  connection  with  the 
abdominal  wall  can  be  readily  determined.  When  suppura- 
tion occurs  these  tumors  may  point  externally.  It  occurs 
not  seldom  that  such  tumors  can  only  be  felt  externally,  the 
hardness  being  beyond  the  range  of  the  finger  per  vaginam. 
When  the  effusion  is  in  relation  to  the  cervix,  the  latter  is 
usually  displaced  in  position.  If  the  inflammatory  products 
are  limited  to  Douglas's  pouch,  the  uterus  is  pushed  directly 
forward,  but  if  the  tissues  to  the  side  are  also  involved,  there 
will  be  more  or  less  lateral  displacement.     Displacement  of 

36* 


426     DISORDERS  OF  THE  FEMALE  ORGANS. 

the  cervix  towards  tlie  side  cori'esponding  with  tlie  inflam- 
mation, is  met  with  in  adhesive  peritonitis.  Tliere  is  olten 
some  ditficiilty  in  discriminating  between  these  inflammatory 
tumors  and  those  arising  from  the  effusion  of  blood  (Pelvic 
Hiematocele).  In  the  acute  form,  the  sudden  onset  of  the 
aflection,  the  rapid  formation  of  the  tumor,  the  evidence  at 
first  of  fluid,  and  the  changes  in  consistence  of  the  swelling, 
accompanied,  it  may  be,  by  pallor,  faihtness,  and  other  evi- 
dence of  loss  of  blood,  are  the  chief  points  to  be  relied  upon 
in  forming  an  opinion.  In  the  chronic  form  the  question  of 
diagnosis  is  more  difficult.  Ovarian  tumors  situated  in  the 
pelvis  are  not  likely  to  be  confounded  with  the  swellings 
above  described  :  their  consistence  and  greater  mobility  are 
generally  sufficient  to  distinguish  them.  It  must  be  remem- 
bered, however,  that  an  ovarian  cyst  may  occupy  the  pouch 
of  Douglas,  and  they  are  also  found  sometimes,  though  rarely, 
in  front  of  tiie  uterus. 

Carcinojia  Uteri. — Malignant  affections  of  the  uterus 
occur  most  frequently  from  the  fortieth  to  the  fiftieth  years, 
but  both  befoi-e  and  after  these  years  they  are  not  infrequent. 
Cancer  is  rare  before  tw^enty-five,  but  a  few  cases  have  been 
recorded ;  and  it  is  occasionally  to  be  met  with  even  to 
the  advanced  age  of  seventy. 

The  sym[)toms  in  their  sequence  and  grouping  vary  very 
considerably  in  different  cases.  There  are  three  special 
symptoms,  wdiich,  either  singly  or  together,  should  arouse 
attention  and  demand  a  careful  examination.  They  are 
pain,  hemorrhage,  and  thin,  watery,  ichorous,  sometimes 
offensive,  discharge.  Cases  occur  w^here  one  or  other  of 
them  may  be  absent.  Their  duration  also  is  variable,  they 
may  succeed  or  alternate  with  one  another.  In  one  case 
hemorrhage  is  the  first  to  arrest  attention,  in  another  it  is 
pain,  in  a  third  there  may  be  only  a  thin  watery  discharge, 
occasionally  tinged  with  blood.  The  pain  has  no  definite 
character  which  is  pathognomonic,  and  yet  it  can  often  be 
recognized.  Persistency  and  a  weary  wearing  out  effect, 
with  severe  exacerbations,  often  periodic,  are  perhaps  its 
special  characteristics.  Frequently  it  is  a  dull  grinding, 
referred  to  the  uterus,  with  sharp  lancinating  and  radiating 
pains.  The  symptoms  are  valuable  only  when  combined 
with  the  physical  signs. 

In  the  majority  of  cases  the  cervix  is  the  portion  aifected, 
but  cases  where  it  is  confined  to  the  body  are  not  so  rare  as 
at  one  time  supposed.     It  is  not  often  that  an  opportunity  is 


CARCINOMA    UTERI.  427 

afforded  of  examining  a  case  in  the  earlier  stage.  The  vaginal 
portion  of  the  cervix  becomes  either  uniformly  indurated  and 
tumefied,  or  numerous  large  tuberosities  are  formed,  causing 
enlargement  of  this  portion  to  three,  four,  or  six  times  the 
normal  size.  The  firmness  diminishes,  the  canal  becomes 
more  patent,  and  as  generally  seen,  there  is  presented  a  large 
ring  or  cup  of  indurated  tissue,  filled  with  softened  pulpy 
tissue  undero-oino;  either  sloughing  or  ulcerative  changes. 
The  uterus  is  at  this  stage  fixed.  The  induration  may  have 
extended  either  as  a  general  infiltration  or  as  nodules  along 
the  vaginal  wall,  involving  the  bladder  or  rectum  or  both. 
At  times  the  vagina  may  be  so  blocked  up  that  the  finger 
can  be  passed  only  a  short  way.  Occasionally  the  disease 
may  present  a  projecting  mass  of  soft,  brain-like,  or  cheesy 
substance,  which  fills  up  the  whole  vagina. 

Epithelial  or  papillary  cancer  (cauliflower  excrescence)  is 
met  with  presenting  somewhat  similar  characters.  The 
cervix  is  enlarged  and  infiltrated ;  from  its  surface  project 
numei'ous  reddish  colored,  readily  bleeding  papillte  or  granu- 
lations, which  finally  form  a  distinct  outgrowth,  irregular  in 
form,  and  divided  into  lobules  of  various  size.  "  They  spring 
from  the  surface  of  the  os  uteri  by  a  short  thick  pedicle  or 
stem,  the  elongated  and  hypertrophied  cervix,  and  then  ex- 
pand below  into  that  peculiar  cauliflower-hke  shape  from 
which  their  name  has  been  derived."  At  first  a  ring  of  ap- 
parently healthy  tissue  can  be  felt  in  the  cervix  above  the 
tumor,  through  which,  in  operating,  the  detachment  is  ef- 
fected. If  left  alone  the  disease  soon  extends  upwards  by 
infiltration,  and  the  neighboring  tissues  become  involved. 

When  the  disease  is  limited  to  the  body  of  the  uterus  the 
physical  signs  are  less  distinct.  The  organ  is  enlarged,  the 
cavity  may  be  lengthened,  but  it  is  also  often  shortened  by 
the  filling  up  of  the  space  with  the  cancerous  growth.  The 
OS  is  frequently  patent.  With  these  changes  the  diagnosis 
is  dependent  upon  the  accompanying  symptoms,  the  frequent 
hemorrhages  with  ichorous  and  intercurrent  offensive  dis- 
charge :  the  pain  is  usually  severe,  and  marked  nocturnal  ex- 
acerbations are  frequently  present.  Certainty  can  be  reached 
by  removing — often  by  the  finger  nail — a  small  portion  of 
the  structure  and  examining  by  the  microscope. 

Fixity  of  the  uterus,  so  constantly  met  with  in  the  later 
stages  of  malignant  disease,  can  be  distinguished  from  that 
found  in  pelvic  inflammations  by  the  absence  in  the  latter  of 


428     DISORDERS  OF  THE  FEMALE  ORGANS. 

the  marked  evidence  of  changes  in  the  structure  of  the  uterus 
itself  met  with  in  cancer. 

A  condition  which  is  liable  to  be  mistaken  for  malignant 
disease  is  where  the  cervix  is  enlarged,  indurated,  witli  patent 
OS  and  ulcerated  surface,  the  result  of  chronic  inflammation. 
The  absence  of  the  surrounding  infiltration  and  fixing  of  the 
uterus,  and  the  characters  of  the  ulcerated  surface,  will  in 
most  cases  be  sufficient  to  determine  their  nature. 

The  above  diseases,  from  their  frequency  and  importance, 
merit  special  attention.  Into  the  diagnosis  of  the  numerous 
affections  to  which  the  pelvic  organs  are  liable,  it  is  impossi- 
ble, from  the  scope  of  the  ])resent  woi'k,  to  enter.  But  in 
conclusion  we  would  remark  that  the  cultivation  of  the 
habit  of  a  careful  and  thorough  exploration  of  the  pelvis  is 
the  only  sure  means  of  guarding  the  practitioner  against 
error.  We  frequently  see  the  attendant  contented  with  the 
diagnosis  of  some  easily  recognized  condition,  such  as  retro- 
version of  the  uterus,  while  he  overlooks  the  true  cause  of 
the  patient's  suffx^ring — pelvic  peritonitis  ;  or  a  pelvic  cellu- 
litis may  remain  unrecognized  because  no  hardness  is  felt 
per  vaghiam ;  still  more  frequently  debility  and  general 
symptoms  have  been  attributed  to  the  stomach,  or  to 
nursing,  or  to  anosmia,  when  there  was  a  pelvic  origin  for 
all,  although  this  remained  unrecognized,  because  the  exam- 
ination was  too  cursory,  or  perhaps  never  thought  of  at  all. 


429 


CHAPTER   XVi. 

THE  PHYSICAL  EXAMINATION  OF  THE  CHEST 
AND  ABDOMEN.' 

PART  I.— PHYSICAL  EXAMINATION  OF  THE  LUNGS. 

Regionally  the  chest  is  usually  divided  as  follows : 
The  Anterior  Regions  are  the  supra-clavicular,  the  suh- 
clavicular,  the  mammary,  the  supra-sternal  (or  the  jugular 
fossa),  and  the  sternal  (upper,  middle,  and  lower).  The 
Lateral  Regions  are  the  axillary  and  the  infra-axillary. 
The  Posterior  Regions  are  the  supra-scapular,  the 
scapular  (including  the  supra-  and  infra-spinous  spaces), 
the  inter-scapular ,  and  the  infra-scapular. 

No  detailed  description  of  these  regions  need  be  given,  as 

'  Amongst  the  books  which  may  be  consulted  regarding  the  Chest 
are,  the  great  works  of  Laennec  on  Mediate  Auscultation,  and  of 
Skoda  on  Auscultation  and  Percussion,  both  of  which  are  trans- 
lated into  English.  The  works  of  Gee  on  Auscultation  and  Percus- 
sion ;  of  Austin  Flint  on  the  Physical  Exjjloration  of  the  chest ; 
of  Payne  Cotton  on  Phthisis  and  the  Stethoscope  ;  and  of  Walshe 
on  Diseases  of  the  Heart  and  Lungs,  are  all  of  very  great  value. 

In  Cardiac  Diagnosis,  the  works  of  Walshe,  Hayden,  George 
Balfour,  and  Sansom  may  be  specially  mentioned  :  the  fourth  vol- 
ume of  Reynolds's  "System  of  Medicine"  contains  a  series  of 
articles  on  this  subject.  Gairdner's  papers  on  Cardiac  Murmurs 
(which  have  been  freely  used  in  this  cliapter)  will  be  found  in  his 
"Clinical  Medicine,"  and  in  the  Glasgow  Medical  Journal  for  1867. 

In  the  Diagnosis  of  Abdominal  Affections,  Murchison,  Budd,  and 
Frerichs  on  Diseases  of  the  Liver  ;  Bennett  on  Leucocythseraia ; 
Brinton,  Fenwick,  Wilson  Fox,  &c.,  on  Diseases  of  the  Stomach  ; 
Spencer  Wells,  Peaslee,  and  Atlee  on  Ovarian  Disease ;  West, 
Graily  Hewitt,  Barnes,  Tliomas,  and  Sir  James  Simpson  on  the 
Diseases  of  Women,  may  all  be  named.  See  also  Chapters  xi., 
xiii.,  and  xv.  of  this  Manual,  and  some  of  the  works  mentioned 
there. 

Amongst  the  older  treatises  of  great  value  may  be  mentioned 
Bright  on  Abdominal  Tumors,  and  Hope,  Stokes,  and  Latham  on 
Cardiac  Diseases. 

Those  who  can  refer  to  the  original  works  of  Von  Dusch,  Paul 
Niemeyer,  Gerhardt,  Piorry,  and  Weil,  will  find  much  of  great 
value  in  the  physical  examination  of  the  organs. 


430       PHYSICAL    EXAMINATION    OF    THE    LUNGS. 

the  names  speak  for  themselves,  and  in  all  cases  where  great 
exactitude  is  required,  it  is  preferable  to  indicate  the  point 
to  be  noted,  not  by  simply  naming  or  subdividing  the  region 
in  which  it  lies,  but  by  taking  some  definite  anatomical  land- 
marks, such  as  a  rib,  the  mid-sternum,  or  the  clavicle,  and 
giving  exact  measurements  from  these  points.  For  this  pur- 
pose the  observer  should  always  be  provided  with  a  measure 
of  length,  and  it  is  Avell  to  have  it  doubly  divided  according 
to  English  inches  and  eighth-parts  of  an  inch,  and  according 
to  the  French  metric  scale  which,  with  its  decimal  sub- 
divisions, is  almost  universally  used  on  the  continent  in  all 
medical  observations.  It  is  convenient  also  to  have  a  scale 
of  inches,  or  of  centimetres,  marked  on  the  upper  surface  of 
the  pleximeter,  but  care  should  be  taken  that  the  markings 
are  accurate  from  end  to  end. 

The  methods  of  investigation  pursued  in  the  physical  ex- 
amination of  the  lungs,  are  Inspection,  Palpation,  Mensura- 
tion, Percussion,  and  Auscultation. 

INSPECTION. 

This  should  be  conducted,  if  possible,  with  the  thorax 
quite  exposed,  but  for  a  variety  of  reasons  it  often  happens 
that  only  a  partial  view  can  be  obtained.  Wlien  it  is  possi- 
ble, the  patient  should  be  placed  in  the  sitting  posture  to 
enable  the  observer  to  view  the  chest  from  all  points,  and 
especially  from  above  downwards  over  the  shoulders.  The 
light  should  be  good  and  should  fall  directly  on  the  chest  ; 
the  attitude  should  be  erect,  yet  unconstrained.  Too  long 
exposure  of  the  chest  is  to  be  avoided,  as  there  is  often  a 
danger  of  catching  cold.  The  points  to  which  attention  is 
directed  in  this  survey  are: — (1)  The  shape  of  the  chest; 
(2)  The  movements  of  its  walls. 

The  Shape  of  the  Chest This  can  be  estimated  in  a 

general  way  by  the  eye ;  but  the  circumferential  shape  is 
accurately  determined  by  the  "  cyrtometer,"  an  instrument 
perfected  by  Woillez ;  and  by  it  also  the  relation  which  the 
two  halves  of  the  thorax  bear  to  each  other  can  be  gauged. 
A  very  handy  form  of  cyrtometer  can  be  improvised  Avith 
two  pieces  of  ordinary  composition  gas-pipe,  united  by  a 
piece  of  india-rubber  tubing  as  a  joint.  The  joint  is  applied 
directly  over  the  spinous  processes  and  held  firmly  in  posi- 
tion. The  two  pieces  of  pipe  are  then  brouglit  round  the 
sides  and  moulded  accm'ately  to  all  the  inequalities  in  the 


THE    SHAPE    OF    THE    CHEST. 


431 


chest  wall.  They  are  ci'ossed  in  front,  the  one  above  the 
other,  and  a  mark  should  be  made  on  them  to  indicate  ex- 
actly the  mesial  line  of"  the  sternum.  The  joint  allows 
them  to  be  removed  without  destroying  the  "  set ;"  the  ap- 
paratus is  adjusted  on  a  sheet  of  paper,  and  a  tracing  made 
with  pencil  or  ink.  The  measurement  is  usually  made  about 
an  inch  below  the  level  of  the  nipple,  or  at  the  sterno-xiphoid 
joint. 

In  the  healthy  child  the  typical  chest  is  somewhat  cir- 
cular, while  in  the  adult  it  takes  the  form  of  an  ellipse,  the 
transverse  diameter  exceeding  the  antero-posterior^  (see 
Fig.  64). 

The  variations  from  the  typical  forms  are  considerable, 
and  are  quite  consistent,  in  many  cases,  with  a  healthv  con- 
dition of  the  thoracic  organs, — occupation,  accident,  and 
various  conditions  inducing  the  changes.  There  are,  how- 
ever, two  typical  deviations  from  the  normal  which  are  tol- 
erably constant  in  their  characters ;  the  one  is  the  "  pigeon- 
breast,"  and  the  other  the  rickety  chest. 

In  the  pigeon-breast  (Fig.  65)  the  sides  are  flattened,  and 
the  sternum  is  carried  in  advance  like  a  keel.  It  occurs  in 
childhood  when  the  ribs  are  yielding  and  adapt  themselves 
readily  to  any  shape,  from  diseases  in  which  great  strain  is 
thrown  upon  the  lungs,  as  in  whooping-cough,  measles,  &c., 
and  is  especially  liable  to  .take  place  in  a  rachitic  subject. 

The  deformity  that  results  from  rickets  alone  is  a  contrast 
to  this  (see  Fig.  66).  In  it  a  constriction  occurs  in  the  late- 
ral region,  and  there  is  not  the  same  sharp  projection  of  the 


•  The  following  table,  given  br  Dr.  Gee,  illustrates  tlie  circnm- 
fereiice,  and  the  ratio  of  the  diameters  to  the  circumference  in 
healthy  chests  at  different  ages.  All  the  measurements  are  taken 
on  a  level  with  the  sterno-xiphoid  joint. 


Actual  Circumfereuce. 

Eatio  of  Diameters  to 
Circumference. 

Age. 

Antero- 
posterior. 

Transverse. 

3  months    . 
2  years  .... 
34      "     .     .     .     . 

48      '^     .     .     .     . 

14|  inches  (37.5  c.) 
18         "      (45.75  c.) 
29f       "      (75  c.) 
35         "      (89  c.) 

26 
26 

26 

27 

29 
32 
35 
31 

432       PBTYSICAL    EXAMINATION    OF    THE    LUNGS. 

Sternum,  as  in  the  pigeon-breast.  Tlie  chest,  in  fact,  becomes 
somewhat  quadrilaterah  These  deformities  do  not  necessa- 
rily indicate  disease  of  the  lungs,  but  are  frequently  associ- 
ated with  it. 


Circumference=S9  centimeters. 

Fig.  64. — Transverse   section  of  healthy  adult   chest  upon  level  of  sterno- 
xiphoid  articulation.    (Dr.  Gee.) 


Circnmference^fiT.o  centimeters. 

Fig.  65. — Pireox-Breast.  Tra^ 
cing  from  a  child  of  seven  years. 
Dotted  line  indicates  the  natural 
shape  at  same  age.     (Dr.  Gee.) 


Circuniference=-12.7.5  centimeters. 

Fig.  66. — RiCKRTT  Chest.  Dotted 
line  indicates  the  shape  of  chest  in  an 
infant  ahout  the  same  age.    (Dr.  Gee.) 


The  two  sides  of  the  chest  are  nearly  symmetrical,  the 
left,  however,  being  usually  a  little  less  in  circumference  than 
the  right.  This  symmetry  is  often  impaii'ed  by  local  condi- 
tions which  may  be  quite  unimportant. 


TRACINGS    WITH    CTRTOMETER. 


433 


Emphysematous  Chest. — In  well-marked  emphysema  there 
is  a  reversion  towards  the  infantile  type,  in  respect  of  the 
altered  proportion  of  tlie  antero-posterior  to  the  transverse 
diameter.  (vSee  the  Table,  p.  431.)  The  chest  becomes 
more  cylindrical,  or,  as  it  is  often  called,  "  barrel-shaped"  ; 
the  sternum  is  more  arched  from  above  downwards  than  in 
the  normal  conditions,  and  the  costal  cartilages,  along  with 
the  sternum,  present  also,  an  excessive  arching  transversely, 
so  that  the  front  of  the  bony  case  seems  unnaturally  bulged 


Fig.  67. — Bilateral  Eslargexext  of  Ejiphtsema. 
laner  line  =enipliysematous  chest. 

Outer  line  =a  circle   drawn   to  show  how   nearly  the  emphysematous   ap- 
proaches the  circular  shape. 
Dotted  line  =natural  adult  chest. 

Actual  measurement  in  centimeters. 
Circumference    ^natural  S7.     enphys.  S7.75. 
Transverse  .     .  =      "       29.6  "       27.2-5. 

Ante.ro-posterior=      "       22.2.3        "       2.5.4 

(Dr.  Oee.) 

forward,  while  the  lower  ribs  are  laterally  compressed.  There 
is,  however,  this  well-marked  difference  between  the  emphy- 
sematous and  most  of  the  infantile  deformities,  that  in  pro- 
portion as  the  former  take  place  after  the  bony  and  cartilagi- 
nous structures  have  been  consolidated,  the  changes  are  gradual 
and  devoid  of  abruptness.  We  rarely  or  never  find,  accord- 
ingly, the  pigeon-breast,  or  the  depressed  and  incurvated 
37 


434       PHYSICAL    EXAMINATION    OF    THE    LUNGS. 

ribs  of  the  rickety  infant  among  the  emphysematous  deformi- 
ties of  adult  age. 

Unilateral  changes  may  also  occur.  Tliere  may  be  bulg- 
ing of  one  side  from  elFusion  of  fluid  or  air  into  tlie  pleural 
sac  ;  tumors  of  the  lung,  such  as  cancer,  have  a  similar 
effect,  and  even  in  pneumonia,  if  it  is  extensive,  there  may 
be  a  slight  but  decided  increase  on  the  affected  side.  Re- 
traction of  one  side  may  occur  from  cicatricial  processes  in 
the  lung  tissue,  as  in  phthisis  or  abscess,  or  from  the  lung 
not  expanding  after  the  absorption  of  a  pleural  effusion  of  air 
or  fluid.  If  the  retraction  is  extreme,  lateral  curvature  of 
the  spine  is  usually  present,  the  convexity  being  directed 
towards  the  sound  lunfj. 


Fig.  68. — Unilateral  retraction  of  chest ;  coasequeat  upon  cirrhosis  of  left 
lung  in  a  girl  of  foiirteen  years.  The  figures  indicate  antero-posterior  and  trans- 
verse diameters,  andsemi-circuraferencesof  right  and  left  half  of  chest  (Dr.  Gee.) 

The  sub-clavicular  regions  always  demand  the  most  care- 
ful inspection,  as  a  degree  of  flattening  often  attends  the 
deposition  of  tubercle. 

Local  bulgings  may  occur  in  the  chest  wall,  in  the  region 
of  the  heart,  from  pericai'dial  effusion  or  extreme  dilatation 
or  hypertrophy  of  the  organ  itself;  and  aneurisms  or  tumors 
in  any  part  of  the  chest  may  give  rise  to  similar  deformities. 

Movements  of  the   Chest    Walls In  estimating  these,  the 

student  must  keep  before  his  mind  the  fact  that  in  women 
the  thorax  moves  more  freely  in  respiration  than  in  men : 


PALPATION.  435 

the  type  being  more  thoracic  in  the  female  and  more  abdom- 
inal in  the  male.  The  movements  should  be  observed  first 
in  quiet  respiration,  and  then  the  patient  should  be  directed 
to  take  one  or  two  deep  breaths,  filling  the  chest  slowly  and 
fully.  Both  inspection  and  palpation  should  be  brought  to 
bear  to  determine  the  amount  of  movement. 

The  thoracic  respiratory  movement  may  be  exaggerated  ; 
and  this  is  especially  the  case  when  the  descent  of  the  dia- 
phragm is  impeded,  as  from  tumoi-s  or  other  conditions  in 
the  abdominal  cavity.  On  the  other  hand,  the  thoracic 
movement  may  be  much  restricted,  and  abdominal  respira- 
tion greatly  exaggerated,  as  in  cases  where  the  respiratory 
forces  of  the  chest  are  at  fault  (as  in  paralysis  of  the  mus- 
cles), and  the  wliole  work  of  respiration  is  thrown  upon  the 
diaphragm.  There  may,  however,  only  be  a  deficiency  in 
the  expansion  of  the  thorax  as  a  whole,  as  in  pronounced 
emphysema,  or  in  the  same  disease  the  lower  zone  may  be 
sucked  in  by  the  action  of  the  diaphnigm,  while  the  upper 
half  is  forcibly  raised  by  the  scaleni  and  sterno-mastoid 
muscles,  without,  however,  there  being  a  corresponding 
amount  of  expansion. 

Movement  may  be  in  abeyance  over  one  side  or  the  other, 
from  extensive  pleuritic  efl'usion,  pneumothorax,  or  from 
retraction  from  old  pleuritic  effusion ;  or  the  restricted  move- 
ment may  only  exist  at  the  base,  the  sound  side  and  upper 
half  of  the  affected  one  being  thrown  into  undue  motion. 
Pneumonia  and  other  consolidations  at  the  base  and  moder- 
ate pleuritic  effusion  give  rise  to  this. 

The  movements  at  the  apices  should  be  critically  observed, 
and  hei-e  inspection  and  palpation  are  very  usefully  com- 
bined. The  observer  stands  behind  the  patient  with  a 
thumb  on  either  scapular  spine,  while  the  tips  of  his  fingers 
lie  over  the  apices  in  front  immediately  beneath  the  clavicles. 
The  patient  is  then  directed  to  inspire  fully  and  quietly,  and 
by  watching  the  rise  and  fall  of  the  fingers  a  very  accurate 
comparison  of  the  two  sides  can  be  made.  Deficient  expan- 
sion at  either  apex  is  a  very  important  fact  -as  indicating 
disease  of  the  lung. 

PALPATION. 

This  has  already  been  referred  to  as  a  very  important  ad- 
junct to  inspection  in  determining  the  expansion  of  the 
upper  part  of  the  chest  (vide  supra),  and  it  will  naturally 


436       PHYSICAL    EXAMINATION    OF    THE    LUNGS. 

occur  to  the  sturlent  to  employ  it  in  estiniiiting  more  exactly 
than  by  inspection  alone,  deficient  or  undue  movement  in 
other  parts  of  the  thorax.  Palpation  will  also  determine  the 
condition  of  the  intercostal  spaces  which  may  be  unduly 
prominent,  resistant,  and  wide,  as  in  cases  of  effusion  into 
the  pleura  either  of  air  or  fluid,  or  in  the  region  of  the  heart 
from  pericardial  effusion  ;  or  they  may  be  diminished  in  size 
by  the  approximation  of  the  ribs,  as  in  cases  of  collapse  or 
shrinking  of  the  lung.  Fluctuation  or  elasticity  may  some- 
times be  detected  in  the  intercostal  spaces  in  cases  of  fluid 
effusion,  and  in  some"  instances  pleuritic  friction  and  the 
grating  sensation  present  in  some  forms  of  emphysema  may 
be  realized.  The  condition  of  the  vocal  resonance  and 
vocal  fremitus,  and  the  presence  of  pulsations  and  thrills 
(cardiac  or  aneurismaJ)  are  also  to  be  noted,  but  these  will 
be  discussed  under  their  respective  heads  (see  pp.  447,  448, 
and  460). 

MENSURATION. 

If  the  circumference  of  the  two  sides  is  required,  the 
student  should  first  mark  in  ink  the  tips  of  the  spinous  pro- 
cesses of  some  of  the  vertebras,  and  in  a  like  manner  the 
mesial  line  of  the  sternum.  The  circumference  of  th.e  two 
sides  is  taken  from  these  points,  the  measurements  being 
made  at  exactly  similar  levels,  the  tape  applied  accurately 
to  the  chest  wall,  and  the  two  observations  made  either  on 
inspiration  or  expiration,  or  on  both.  The  level  most  com- 
monly selected  for  the  measurements  is  about  two  inches 
below  the  nipple  in  a  line  with  the  sterno-xiphoid  joint,  the 
advantages  of  this  situation  being  that  it  is  quite  free  from 
bulky  muscles  and  below  the  scapuke.  A  very  convenient 
method  of  measurement  is  by  the  double  tape,  which  is 
simply  two  tapes  joined.  Their  line  of  junction  is  placed 
exactly  over  the  spinous  processes,  they  are  brought  round 
on  either  side,  and  the  circumferences  of  the  two  hsdves  can 
be  read  off  at  once  and  their  relative  degrees  of  expansion 
noted. 

In  the  average  healthy  chest  the  right  side  is  usually 
found  to  exceed  the  left  in  circumference  by  about  three- 
fourths  of  an  inch.  But  the  circumference  of  either  side 
may  be  increased  from  morbid  conditions,  such  as  effusion  of 
air  or  fluid  into  the  pleura  or  pericardium,  in  unilateral 
emphysema,  or  in  cases  of  tumor.     In  oedema  of  the  chest 


PERCUSSION.  43T 

wall  also,  if  the  patient  lies  habitually  or  for  any  length  of 
time  on  the  one  side,  the  fluid  will  gravitate  so  as  to  in- 
crease the  circumference  on  that  side.  But  the  circumfer- 
ence may  be  diminished  from  shrinking  of  the  chest  wall  in 
collapse  of  the  lung,  after  pleural  effusion  or  from  retraction 
in  phthisis.  Discrepancies  may  also  arise  from  deformities 
of  the  walls  or  from  curvature  of  the  spine.  (See  shape  of 
chest  as  gauged  by  the  cyrtometer,  Fig.  68,  p.  434.) 

The  antero-posterior  diameter  of  the  chest  may  be  esti- 
mated by  the  cyrtometer  or  by  callipers,  one  blade  being 
placed  in  front  and  the  other  behind  ;  and  the  movements  of 
respiration  may  be  accurately  determined  by  the  '■'chest 
measurer^'  of  Dr.  Sibson,  or  the  stethometer  of  Dr.  Quain, 
both  of  which  indicate  on  a  dial  the  degree  of  expansion. 
The  spirometer  of  Dr.  Hutchinson,  Avhich  measures  the 
quantity  of  air  breathed  out,  is  used  to  determine  the  '•'  vital 
capacity"  of  the  lungs ;  while  the  stethograph  of  Ransome 
gives  tracings  of  the  movements  of  the  chest  walls.  All 
these  instruments,  however,  are  of  much  more  value  in 
physiological  than  in  clinical  investigation.  Dr.  Eansome's 
"  chest  rule"  may  also  occasionally  be  used  with  advantage 
to  note  accurately  the  area  of  any  percussion-dulness,  or  the 
exact  position  of  any  pulsation,  auscultatory  phenomenon, 
&c.,  which  it  may  be  necessary  to  record. 

PERCUSSION. 

This  may  be  performed  Avithout  any  instrument,  the  fingers 
of  the  one  hand  acting  as  the  •'  plessor,"  and  those  of  the 
other  as  the  "  pleximeter."  But  the  Ivor}"  pleximeter  of  M. 
Piorry  may  be  used  and  the  stroke  dealt  by  Wintrich's 
hammer.  This  last  is  as  a  rule  only  useful  for  purposes  of 
demonstration  to  a  large  class  or  to  educe  sounds  which  re- 
quire a  strong  stroke,  e.  g.  the  "  cracked-pot  sound"  or  to 
elicit  the  note  in  parts  thickly  padded  with  muscle  as  in  the 
supra-spinous  regions  in  the  back.  When  the  pleximeter  is 
used  it  should  be  firmly  and  closely  applied  to  the  skin,  the 
percussing  stroke  should  be  delivered  on  its  centre,  and  if 
the  finger  is  used  as  the  plessor,  care  should  be  taken  that 
the  nail  does  not  impinge  upon  the  ivory.  But  the  fingers 
give  the  most  delicate  results,  and  in  very  critical  percussion 
they  are  indispensable,  as  they  enable  the  percussor  to  esti- 
mate the  degree  of  resistance  to  his  stroke  with  greater  deli- 
cacy than  by  any  other  method.     The  stroke  should  be  de- 

3t* 


438       PHYSICAL    EXAMINATION    OF    THE    LUNG'S. 

livered  as  directly  and  perpendicular  as  possible,  with  a  well 
controlled  movement  from  the  wrist  and  not  from  tlie  elbow. 
Care  should  be  taken  that  no  sound  is  generated  by  the  con- 
tact of  the  nails.  Occasionally  immediate  or  direct  percus- 
sion is  employed,  the  fingers  striking  the  chest  wall  directly. 
This  is  especially  useful  in  the  clavicular  region,  the  bone 
acting  as  a  kind  of  pleximeter. 

In  the  back  of  the  chest  the  lower  limit  of  lung-percussion 
is  on  a  level  with  the  tenth  or  eleventh  dorsal  spine.  In  front 
on  the  right  side  it  is  bounded  inferiorly  by  the  upper  border 
of  hepatic  dulness,  i.  e.  about  1^  inches  below  the  nipple, 
while  on  the  left  side  it  is  bounded  at  the  lower  border  of  the 
third  rib  by  the  cardiac  dulness,  and  in  the  left  lateral  region 
by  the  stomach  and  spleen.  In  the  upper  front,  the  apices 
of  the  lungs  project  to  some  extent  above  the  clavicles  into 
the  supra-clavicular  spaces. 

The  parts  of  the  chest  which  should  be  most  carefully  per- 
cussed are  the  apices  both  in  front  and  behind,  the  inter-scap- 
ular regions,  the  axillary  regions,  and  the  bases.  Each  point 
on  one  side  should  be  carefully  contrasted  with  a  similar 
point  on  the  other,  and  in  many  instances  also  with  different 
parts  on  the  same  side.  Every  stroke  should  be  made  to 
yield  results,  and  no  spot  should  be  lingered  over  separately 
and  without  comparison  with  others,  as  the  ear  is  apt  to  get 
confused.  If  dull  percussion  is  detected,  especially  in  the 
lower  part  of  the  chest,  it  should  be  tested  with  the  patient 
in  various  attitudes,  for  pleuritic  effusions,  if  free,  will  be 
found,  in  some  instances,  to  obey  the  law  of  fluid  level,  and 
the  area  of  dulness  will  vary  with  the  position  of  the  patient. 
This  is  especially  marked  in  cases  of  hydro-pneumothorax. 
In  percussing  above  the  clavicle,  care  should  be  taken  that 
the  stroke  is  directed  aw^ay  from  the  trachea.  It  is  also  well 
to  remember  that  in  health  the  percussion  note  of  the  left 
apex,  especially  in  women,  is  often  a  little  flatter  than  the 
right. 

Over  the  healthy  lung  the  percussion  note  is  termed  "  clear^' 
and  the  junior  student  will  do  Avell  to  contrast  it  carefully 
with  the  note  obtained  over  the  stomach,  which  is  "  tympa- 
nitic'' and  drum-like,  and  that  over  the  liver,  which  is  "  dull" 
No  uniform  standard  can  be  set  up  for  the  pulmonary  note 
in  all  cases,  as  there  are  so  many  modifying  circumstances. 
For  instance,  if  the  chest  walls  are  well  covered  with  muscle 
or  fat,  the  pulmonary  note  may  be  very  obscure,  especially 
in  the  back  ;  and  in  such  cases  it  is  only  by  a  careful   com- 


HYPER-RESONANCE    AND    DULNESS.  439 

parison  of  all  parts  of  the  chest  that  the    standard  can   be 
arrived  at. 

The  percussion  note  over  the  lungs  may  depart  from  the 
normal  in  the  direction  either  of  hyper-resonance  or  of  dul- 
ness.  If  over  one  side  of  the  chest  a  frankly  tympanitic  note 
is  got,  pneumothorax  should  be  suspected,  and  other  signs 
will  generally  confirm  .the  diagnosis.  But  a  more  localized 
and  less  pronounced  tympanitic  note  may  be  obtained  in 
many  instances  at  the  apex  of  a  lung  from  tubercular  excava- 
tion if  near  the  surface  ;  or  where  there  is  consolidation  of 
the  lower  lobe  as  in  pneumonia ;  or  if  the  lower  lobe  is  com- 
pressed by  pleural  eifusion,  especially  if  that  effusion  is 
advancing  or  beginning  to  recede.  In  these  latter  cases, 
however,  the  tympanitic  quantity  is  usually  associated  with 
some  diminution  of  resonance  so  that  the  note  is  so  far  dull. 
In  emphysematous  conditions  of  the  lungs  the  mass  of  the 
percussion  tone  is  increased  or  exaggerated,  while  at  the 
same  time  it  is  lowered  in  j)itch. 

Dulness  over  the  lungs  may  be  due  to  changes  in  the 
organs  themselves,  or  in  the  pleurae.  All  forms  of  pulmon- 
ary condensations  lead  to  it,  such  as  pneumonia,  tubercular 
or  cancerous  disease,  oedema,  congestion,  collapse,  &c.  The 
dulness  in  such  cases  may  affect  any  part  of  the  lung,  but  in 
the  great  majority  of  instances  the  bases  are  chiefly  in- 
volved. Tubercular  consolidation  is  a  marked  exception  to 
this,  however,  the  apices  being  most  frequently  affected,  the 
first  hints  of  it  being  often  obtained  by  a  change  in  the  per- 
cussion note  in  the  supra-clavicular  spaces. 

Dulness  depending  on  changes  in  the  pleura  may  result 
from  thick  layers  of  lymph  or  fluid  effusion,  in  which,  if  it  is 
moderate  and  free,  the  dulness  will  gravitate  to  the  base, 
but  if  the  effusion  is  large  the  whole  side  may  yield  an  abso- 
lutely dull  note,  and  it  may  even  cross  the  mesial  line,  and 
reach  above  the  clavicle  (see  Fig.  73,  p.  460).  The  dull 
note  in  rare  cases  may  depend  on  pneumothorax,  whei*e  the 
air  is  present  in  such  quantity  as  to  distend  the  pleural 
cavity  to  its  utmost.  If  a  little  air  is  let  off  in  such  in- 
stances by  a  hollow  needle,  a  tympanitic  note  becomes  devel- 
oped. Thickening  of  the  pleura  will  diminish  the  pulmonary 
resonance,  and  in  collapse  of  the  lung  with  retraction  of  the 
side,  it  will,  of  course,  be  seriously  impaired  if  not  altogether 
lost. 

But  areas  of  dull  percussion  may  occur  from  other  causes 
than  changes  in  the  lungs  or  pleuras.     Thus  aneurisms  or 


440        PHYSICAL    EXAMINATION    OF    THE    LUNGS. 

dilatations  of  tbe  aorta,  glandular  tumors,  cancer,  pericardial 
effusion,  or  dilated  or  hypertropliied  conditions  of  the  heart 
may  encroach  on  the  limits  of  lung-percussion.  These  areas 
should  be  carefully  mapped  out,  and  other  signs  will  usually 
guide  the  diagnosis.  The  displacements  of  the  heart  are 
considered  under  the  head  of  cardiac  diagnosis  (see  page  459). 
The  cracked-pot  sound  (Bruit  de  pot  fele)  demands  special 
mention.  It  is  a  modification  of  the  tympanitic,  and  can  be 
■well  imitated  by  striking  the  hands  folded  across  each  other 
over  the  knee.  The  best  method  to  elicit  it  is  by  a  strong 
stroke,  and  this  is  one  of  the  instances  for  the  use  of  the 
percussing  hammer.  The  patient  should  keep  his  mouth 
open  and  breathe  quietly.  In  the  adult  this  sign  generally 
indicates  a  cavity  in  the  lungs,  but  it  may  be  present  in 
healthy  children,  owing  to  the  yielding  nature  of  the  chest 
walls.  Walshe  says  it  is  usually  got  over  the  chest  of  a  cry- 
ing infant  on  expiration.  If  a  patient,  who  develo[)S  this 
sign,  inspires  deeply  and  then  holds  his  breath,  the  cracked- 
pot  sound  will  disappear. 

AUSCULTATION. 

Auscultation  of  the  lungs  may  be  conducted  either  ???e- 
diately  by  the  stethoscope,  or  immediately  by  the  application 
of  the  ear  to  the  chest  wall.  The  former  is  the  method 
more  commonly  employed  in  this  country,  although  in  cer- 
tain instances,  especially  in  the  auscultation  of  children,  who 
are  easily  frightened  by  the  sight  or  pressure  of  the  stetho- 
scope, the  direct  method  may  be  more  advantageous.  In 
adults  also  it  is  often  well  to  auscultate  the  back  of  the  chest 
immediately,  a  thin  soft  towel  or  handkerchief  being  inter- 
posed between  the  ear  and  the  skin.  In  selecting  a  stetho- 
scope the  student  should  see  that  it  fits  his  ear  accurately. 
The  form  of  the  instrument  is  not  of  very  much  consequence, 
and  it  may  be  made  of  metal,  vulcanite,  or  wood.  The 
ear-piece  should  be  large  enough  to  cover  the  whole  concha, 
say  from  2^  to  2|  inches  in  diameter,  and  slightly  concave 
to  admit  of  the  exact  application  of  the  ear.  The  bell 
should  be  large  enough  to  bridge  over  an  intercostal  space, 
from  one  and  a  sixth  to  one  and  a  quarter  inch  in  diameter. 

When  used  the  stethoscope  should  be  applied  directly  to 
the  chest  without  the  intervention  of  any  clothing,  and  it  is 
necessary  that  it  should  be  planted  quite  fairly,  so  that  the 
whole  of  the  circumference  of  the  bell  may  be  in  contact 


PULMONARY    AUSCULTATION,        .  441 

"vvitli  the  skin.  Moderate  pressure  with  the  head  toII  keep 
it  in  position,  but  care  should  be  taken  that  undue  pressure 
is  not  exerted,  as  it  not  only  causes  pain  but  may  even 
impede  respiration  to  some  extent.  Beginners,  as  a  rule, 
are  apt  to  press  far  too  heavily.  Care  must  be  taken  to 
obviate  friction  between  any  part  of  the  patient's  dress  and 
the  stethoscope,  or  between  the  patient's  dress  and  his  skin 
in  the  vicinity  of  the  instrument.  In  patients  who  have 
much  hair  developed  on  the  chest,  the  student  must  be  care- 
ful that  he  does  not  mistake  the  friction  of  the  hair  with  the 
stethoscope  during  the  act  of  respiration  for  an  intrathoracic 
sound.  This  fallacy  may  be  avoided  by  shaving  the  part,  or 
having  the  bell  of  the  stethoscope  shod  with  a  piece  of  india- 
rubber.  The  differential  stethoscope  of  Dr.  Scott  Alison 
may  occasionally  be  employed  in  the  physical  examination 
of  the  lungs,  but  it  is  of  much  more  importance  in  cardiac 
diagnosis,  especially  in  determining  the  rhythm  of  murmurs. 
It  consists  simply  of  two  stethoscopes,  with  flexible  .stems, 
leading  separately  to  each  ear,  and  connected  by  a  joint. 
The  ear-pieces  are  small  and  fit  into  the  ears,  while  the 
flexible  stems  allow  of  the  bells  being  placed  at  a  greater  or 
less  distance  from  each  other  according  to  the  desire  of  the 
auscultator.  A  new  form  of  differential  stethoscope  has  been 
introduced  by  Dr.  Spencer,  in  which  the  sounds  from  each 
tube  are  communicated  to  both  ears. 

During  auscultation  both  the  patient  and  the  observer 
should  be  in  an  easy  posture.  The  patient  should  lie  quite 
flat  or  sit  unconstrainedly,  all  muscular  effort  being  in  abey- 
ance, and  the  auscultator  should  avoid  stooping  or  straining 
too  much  over  the  patient.  A  very  thorough  examination 
can  also  be  made  with  the  patient  standing  erect,  a  blanket 
or  shawl  being  cast  over  his  shoulders  to  prevent  any  chill. 
The  examination  should  be  carried  out  quietly  and  system- 
atically, the  various  regions  of  the  chest  being,  as  far  as 
possible,  symmetrically  examined  and  carefully  contrasted. 
It  is  often  necessary  also  to  contrast  diflTerent  parts  on  the 
same  side.  The  patient  should  be  directed  to  breathe 
quietly  or  forcibly,  according  as  circumstances  demand,  and 
it  is  well  in  most  cases  to  listen  under  both  conditions, 
always  taking  care,  however,  that  quiet  respiration  is  first 
selected.  A  fact  of  importance  is,  that  forced  inspiration 
should  not  be  performed  spasmodically,  or  with  noise  in  the 
mouth  or  nose,  but  slowly  and  quietly.  A  thorough  exam- 
ination  of  all   parts   of  the  lung  is  necessary,  but  special 


442       PHYSICAL    EXAMINATION    OP    THE    LUNGS. 

attention  should  be  paid  to  the  apex,  both  in  front  and  be- 
hind, to  tlie  HxiUaiy  region,  the  inter-scapular  region,  to  the 
base  behind,  and  to  any  region  where  pain  is  complained  of. 
The  student  must  be  careful  not  to  confuse  his  ear  by  linger- 
ing too  long  over  the  same  spot ;  it  is  much  better  to  return 
to  it.  The  examination  sliould  be  conducted  with  as  little 
fatigue  to  the  patient  as  possible,  and  with  this  end  in  view, 
as  well  as  to  avoid  unnecessary  repetition,  each  spot  on  the 
one  side  should  be  compared  with  a  corresponding  point  on 
the  other :  exact  comparative  results  are  thus  obtained. 

The  principal  objects  for  which  auscultation  of  the  lungs 
is  practised  are  :  1,  To  ascertain  the  condition  of  the  respira- 
tory murmur  or  breath  sounds  ;  2,  To  detect  the  presence  of 
any  superadded  abnormal  sounds  or  rsLles  ;  3,  To  ascertain 
any  alteration  in  the  vocal  resonance  or  fremitus,  or  in  the 
transmission  of  the  heart's  sounds. 

BREATH  SOUNDS. 

To  ascertain  the  condition  of  the  breath  sounds.  In  this 
as  in  all  other  departments  of  physical  diagnosis,  the  student 
must  be  acquainted  with  the  healthy  phenomena  before  he 
can  hope  to  detect  morbid  changes.  There  are  three  facts 
then  with  which  he  must  make  himself  perfectly  familiar  in 
the  healthy  chest,  viz.,  the  character  of  the  breath  sounds  as 
heard  over  the  trachea,  over  a  bronchial  tube,  and  over  the 
spongy  lung  tissue.  The  breath  sounds  over  the  trachea  are 
loud,  hollow,  articulate,  and  the  expiration  and  inspiration 
are  equal  in  length  and  intensity,  but  separated  by  a  distinct 
interval.  Bronchial  respiration  is  heard  to  greatest  advan- 
tage near  the  sterno-clavicular  articulations  or  in  the  inter- 
scapular spaces  near  the  spine.  It  approximates  in  character 
to  the  tracheal,  but  is  less  pronounced. 

The  vesicular  or  resjyiratory  murmur  proper  is  heard 
over  the  spongy  lung,  and  may  be  found  in  its  most  typical 
form  in  the  lower  half  of  the  back,  two  or  three  inches  from 
the  spine,  or  in  the  lateral  region.  It  is  soft,  bi'eezy,  and 
uniform  ;  and  although  the  inspiratory  and  expiratory  sounds 
are  the  same  in  quality,  they  differ  in  degree  and  prolonga- 
tion, the  expiratory  being  less  loud  and  only  about  one-third 
the  length  of  the  inspiratory.  The  interval  between  the  two 
acts  is  of  very  short  duration.  It  is  to  be  remarked  that 
the  inspiratory  murmur  is  normally  louder  and  harsher  in 
children  than  in  adults  (hence  called  puerile),  that  in  old 


YESICULAR    MURMLR.  443 

age  it  tends  to  become  feebler,  and  that  it  is  usually  more 
marked  in  men  than  in  -women.  It  is  also  to  be  expected 
that  in  an  emaciated  subject  the  respiratory  murmur  will  be 
more  audible  than  in  one  with  well-developed  muscular  and 
fatty  tissues.  Besides  these  there  are  variations  which  can- 
not be  accounted  for  on  any  pliysical  principle,  and  which 
may  be  regarded  as  individual  peculiarities,  some  men 
having  extremely  feeble,  almost  inappreciable  respiratory 
murmur  throughout  the  chest,  while  others  have  respiration 
which  may  almost  be  described  as  puerile,  both  conditions 
being  quite  compatible  with  an  absolutely  normal  state  of  the 
lungs  and  air  passages. 

Hie  vesicular  murmur  may  und.ergo  various  changes  in 
disease.  It  may  become  ioec(J:ened  or  suppressed.  Weaken- 
ing of  the  respiratory  murmur  may  result  from  some  obstruc- 
tion, such  as  pressure  of  an  aneurism  on  a  bronchus,  or 
spasm  of  a  bronchus ;  or  from  some  obstruction  in  the 
larynx  and  trachea  hindering  the  free  admission  of  air  into 
the  pulmonary  vesicles.  It  may  also  result  from  pulmonary 
condensation,  collapse,  or  emphysema.  Absolute  suppres- 
sion occurs  in  cases  of  large  effusion  either  of  serum  (hydro- 
thorax),  or  of  pus  (empyema),  or  of  air  (pneumothorax), 
into  the  pleural  sac.  In  certain  cases  of  condensation  and 
collapse  of  the  lung,  the  I'espiratory  murmur  may  be  quite 
suppressed  or  replaced  by  some  other  form  of  respiration, 
such  as  the  bronchial. 

The  respiratory  murmur  may  be  exaggerated,  or  as  it  is 
technically  called  puerile.  In  children  the  normal  respira- 
tory murmur  is  of  this  type,  but  in  the  adult  its  presence 
usually  indicates  that  although  the  part  of  the  lung  over 
Avliich  it  is  heard  may  be  healthy,  some  other  part  is  sutfer- 
ing  from  causes  leading  to  suppression  or  diminution  of  the 
respiratory  murmur.  It  is  heard  at  the  apex  of  a  lung,  for 
instance,  when  the  lower  part  is  compressed  by  pleuritic 
eff'usion,  or  when  the  base  is  consolidated ;  or  if  owing  to 
any  cause  the  function  of  one  lung  is  much  crippled,  the 
respiratory  murmur  is  often  exaggerated  on  the  other  side. 
All  these  facts  indicate  its  compensatory  nature. 

Jerky,  wavy,  sighing,  or  cog-wheel  respiration,  is  the 
term  applied  to  the  respiratory  murmur  when  it  loses  its  con- 
tinuous character  and  gets  broken  up  into  parts,  or  into  a 
series  of  little  waves.  It  is  the  inspiratory  murmur  almost 
exclusively  which  is  afl^ected  in  this  manner.  It  is  not  in- 
dicative of  any  positive  disease,  but  should  always  be  re- 


444       PHYSICAL    EXAMINATION    OF    THE    LUNGS. 

gardecl  with  suspicion,  especially  if  it   is  local  and  at  the 
apex,  as  an  early  indication  of  phthisis. 

Prolongation  of  the  expiration.  It  has  already  been 
stated  that  normally  the  exjnratory  murmur  is  much  shorter 
than  the  inspiratory,  but  in  many  cases  it  becomes  so  length- 
ened as  to  equal  the  inspiration,  and  in  some  instances  even 
to  exceed  it.  It  is^a  frequent  indication  of  the  early  stage 
of  tubercular  deposition,  and  in  such  cases  is  usually  asso- 
ciated with  a  degree  of  harshness  or  exaggeration  of  the 
respiratory  murmur.  In  vesicidar  emphysema,  owing  to 
over-distension  of  the  air  vesicles  and  consequent  loss  of 
elasticity  in  their  walls,  this  prolongation  of  the  expiration 
is  very  marked,  and  is  associated  with  Aveakening  of  the 
inspiratory  murmur. 

But  the  respiratory  murmur,  besides  these  alterations  in 
it,  may  come  to  assume  a  totally  diiferent  quality ;  it  is  re- 
placed, in  fact,  by  breathing  of  another  type.  The  changes 
in  quality  are  indicated  by  the  terms  Bronchial.,  Tubular., 
Cavernous,  and  Amphoric.  Several  of  these  differ  most 
probably  only  in  degree,  and  all  of  them  may  be  heard  at 
different  stages  in  a  case  of  phthisis  going  on  to  excavation,  . 
as  well  as  in  other  affections  having  a  similar  tendency. 

Bronchial  and  Tubular  respiration,  as  has  been  already 
stated,  is  heard  in  the  healthy  subject  over  the  trachea  and 
large  bronchi,  but  in  certain  forms  of  disease  it  is  present 
over  the  spongy  lung.  It  occurs  in  consolidation  and  col- 
lapse. It  is  heard  in  pneumonia  in  the  stage  of  hepatization, 
in  phthisis,  and  in  cancer  of  the  lung.  It  is  occasionally  also 
heard  in  cases  of  pleuritic  effusion.  In  pleurisy,  with  large 
effusion,  where  the  lung  is  squeezed  to  the  upper  and  back 
part  of  the  chest,  bronchial  respiration  is  often  heard  in  this 
situation. 

Cavernous  respiration  has  the  same  hollow  and  articulate 
quality  as  that  heard  over  the  trachea,  and  if  these  characters 
are  present  over  a  limited  area  and  not  in  the  immediate 
vicinity  of  a  bronchial  tube,  and  especially  if  associated  with 
the  metallic  phenomena  (to  be  afterwards  described),  the 
probability  is  that  a  cavity  exists.  All  conditions  that  lead 
to  excavation  in  the  lung  tissue  produce  it,  and  among  these 
phthisis  is  by  far  the  most  frequent.  Dilated  bronchi  may 
also  give  rise  to  it.  Amorphic  respiration  is  just  a  more  ex- 
quisite degree  of  the  cavernous,  and  can  be  well  imitated  by 
blowing  across  the  mouth  of  a  large  empty  jar.  It  is  heard 
in  large  iutra-pulmonary  cavities,  and  in  cases  of  pneumo- 


RALES.  445 

thorax  where  there  is  a  communication  between  the  Lung  and 
the  pleural  sac.     (See  also  p.  446.) 

RALES. 

The  respiratory  murmur,  however,  may  be  accompanied 
or  replaced  by  other  sounds  called  Rales.  These  may  be 
classified  as — (1)  Sonorous  and  Sibilant;  (2)  Mucous  or 
Bubbling  ;  (3)  Crepitant.  Friction  sound  is  not  usually 
classified  among  the  rales,  but,  in  many  instances,  it  so 
closely  resembles  or  is  so  closely  simulated  by  intra-pulmo- 
nary  sounds,  that  it  seems  well  to  treat  of  it  in  this  connec- 
tion. Various  combinations  of  these  rales  occur  and  must  be 
named  accordingly. 

Sonorous  and  sibilant  rd'es.  These  are  dry  and  somewhat 
musical  ;  they  are  caused  probably  by  some  obstruction  to 
the  tide  of  air  in  the  bronchial  tubes.  The  sonorous  or 
snoring  r&les  are  of  a  grave  pitch,  loud,  and  usually  accom- 
pany both  inspiration  and  expiration,  but  the  pitch  may  vary 
in  the  two  acts.  The  sibilant  (wheezing,  whistling,  cooing, 
&c.)  are  high  in  pitch,  but  in  other  characters  resemble  the 
sonorous.  These  rales  are  heard  most  typically  in  acute  and 
chronic  bronchitis  ;  and  in  asthma,  from  spasmodic  constric- 
tion of  the  bronchial  tubes.  The  two  forms  of  r&le  are  usu- 
ally associated ;  they  vary  much  from  time  to  time,  and  may 
disappear  after  a  cough. 

bubbling  or  mucous  rale.  This  rdle,  in  typical  form,  un- 
questionably gives  the  ear  the  impression  of  moisture,  like 
the  bubbling  of  air  through  some  viscid  fluid.  It  often  exists 
both  with  inspiration  and  expiration,  and  varies  greatly  in 
its  degree,  sometimes  approaching  to  the  characters  of  the 
crepitant  rale,  and  then  called  "  sub-crepitant"  by  some  au- 
thors, while  at  other  times  it  is  large,  coarse,  and  quite  de- 
cidedly mucous.  It  may,  in  severe  cases,  be  present  all  over 
the  lung,  but  as  a  rule  is  most  abundant  at  the  base.  It  is 
common  in  bronchitis  where  the  secretion  of  mucus  is  abun- 
dant ;  in  (Edematous  states  of  the  lung  owing  to  disease  of 
the  heart  or  kidneys  ;  and  in  certain  fevers,  such  as  typhus, 
owing  to  congestion.  In  the  stage  of  resolution  in  pneumonia 
the  rale  known  as  the  crepitus  redux  is  essentially  a  mucous 
rale,  and  the  clicking  rale  of  phthisis  is  also  moist.  This  rale 
in  phthisis  is  so  significant  as  to  demand  special  mention. 
It  is  very  distinctly  moist  and  clicking,  often  very  scanty, 
limited  in  its  area,  chiefly  accompanying  inspiration,  and 
38 


446        PHYSICAL    EXAMINATION    OF    THE    LUNGS. 

having  a  marked  tendencr  to  develop  at  the  apices.  It  is 
ver^'  significant  of  softening  tubercle.  The  cavernous  rale 
may  also  be  considered  as  a  modification  of  the  mucous.  It 
is  present  in  cases  of  cavity  from  tubercular  disease  or  dilated 
bronchi.  It  usually  accompanies  both  expiration  and  inspi- 
ration, is  heard  over  a  limited  area,  and  if  the  patient  coughs 
it  often  has  a  splashing  or  gurgling  quality,  each  splash  being 
folloAved  by  an  aftertone  or  eclio. 

Crepitant  rale.  This  is  a  finer  r^le  than  the  mucous,  and 
is  not  distinctly  moist.  It  is  heard  in  its  typical  form  in 
the  first  stage  of  pneumonia,  prior  to  consolidation,  and  con- 
stitutes the  'pneumonic  crepitus.  This  is  heard,  as  a  rule, 
on  inspiration  only,  often  just  at  the  end  of  it,  and  consists 
of  a  number  of  minute  crackles.  It  can  be  well  simulated 
bv  rubbing  a  lock  of  hair  between  the  fingers  near  the  ear. 
The  rale  is  extinguished  on  the  supervention  of  bronchial 
respiration.  Crepitant  rale  is  also  present  in  cedema  of  the 
lungs,  and  acute  capillary  bronchitis,  and  certain  forms  of 
pleuritic  friction  often  closely  resemble  it. 

Friction  sound  is  produced  in  the  pleura,  owing  to  the 
roughened  surfaces  grating  on  each  other,  and  in  its  most 
exquisite  form  it  is  ea^y  of  recognition.  It  is  distinctly  rub- 
bing or  grating,  very  superficial,  and  usually  accompanies 
both  expiration  and  inspiration,  but  it  may  be  with  inspira- 
tion alone.  Its  most  frequent  seats  are  in  the  mammary 
region,  in  the  lateral  region  in  the  line  of  the  axilla,  or  fur- 
ther round,  near  the  inferior  angle  of  the  scapula.  It  is 
often  accompanied  by  an  unchanged  condition  of  the  respira- 
torv  murmur,  and  forced  inspiration  and  coughing  do  not 
obliterate  it ;  indeed,  forced  inspiration  is  often  required  to 
bring  it  out.  In  many  cases  its  characters  are  not  so  pro- 
nounced, and  it  is  often  mixed  up  with  intra-pulmonary 
ra'es,  which  tend  furthc-r  to  oljscure  the  diagnosis.  In  rare 
cases  friction  is  caused  in  a  roughened  pleura  by  the  cardiac 
action.  This  is  heard  on  the  confines  of  the  heart,  and  is 
distinctly  related  to  the  cardiac  action,  as  may  be  found  by 
its  continuing  when  we  get  the  patient  to  stop  breathing, 

METALLIC  AXL  AMPHORIC  PHEXOMEXA. 

There  is  yet  a  certain  group  of  auscultatory  signs  which 
may  be  classed  under  the  title  of  Metallic  Phenomena. 
These  are  Metallic  Tinkling,  Amphoric  Echo,  the  Bell 
Sound,  and  Hippocratic  Succussion.     All  these  phenomena 


VOCAL    KESONANCE    AND    FREMITUS.  447 

are  very  V3,riable  in  their  degree  and  persistence,  and  they 
occur  in  different  combinations. 

Metallic  tinkling  is  well  described  by  Laennec  as  "a  pe- 
culiar sound,  which  bears  a  striking  resemblance  to  that 
emitted  by  a  cup  of  metal,  glass,  or  porcelain  when  gently 
struck  with  a  pin,  or  into  which  a  grain  of  sand  is  dropped." 
It  may  be  heard  with  respiration,  voice  or  cough — most 
typically  with  the  last  two.  It  is  very  significant  of  cavity, 
and  is  present  in  large  pulmonary  excavations  when  near  the 
surface  of  the  lung,  and  also  in  pneumothorax. 

Amphoric  Echo.  This  term  is  applied  when  the  voice, 
cough,  or  breath  sounds  liave  an  intensely  hollow  resonance, 
and  it  can  be  well  imitatf^d  by  speaking,  coughing,  or  breath- 
ing into  a  large  empty  jar.  It  very  frequently  accompanies 
metallic  tinkling,  or  may  be  interchangeable  with  it.  It  is 
only  present  when  large  masses  of  air  are  thrown  into  vibra- 
tion, and  occurs  most  frequently  in  pneumothorax,  although 
it  may  occasionally  be  heard  in  intra-pulmonary  cavities  of 
large  size.  It  may  accompany  respiration,  voice,  or  cough, 
but  is  usually  most  pronounced  witli  the  two  last. 

The  Bell  Sound  may  be  elicited  by  percussing  the  chest 
with  two  coins  (half-crowns  do  very  well),  the  one  coin 
being  used  as  the  pleximeter  and  the  other  as  the  plessor. 
If  percussion  is  made  at  the  front  of  the  chest  the  auscultator 
applies  his  ear  to  the  same  side  behind,  and  he  may  hear  a 
clear  ringing  sound.  This  sign  is  almost  exclusively  con- 
fined to  pneumothorax. 

Hippocratic  Succussion  is  produced  when  there  is  a  mix- 
ture of  air  and  fluid  in  the  pleural  sac  (Hydro-  or  Pyo- 
pneumothorax). The  best  way  to  elicit  it  is  for  the 
auscultator  to  apply  his  ear  directly  to  the  back  or  side  of 
the  chest  and,  half  embracing  the  patient,  to  give  him  a 
shake.  The  sound  heard  is  similar  to  what  is  got  by  shaking 
a  cask  which  contains  air  and  fluid. 

VOCAL  RESONANCE  AND  FREMITUS. 

The  next  great  object  of  auscultation  over  the  lungs  is  to 
ascertain  any  alteration  in  the  vocal  resonance  or  fremitus, 
or  in  the  transmission  of  the  heart's  sounds. 

Vocal  resonance  is  the  term  applied  to  the  vibrations 
caused  by  the  voice  of  the  patient  transmitted  through  the 
chest  to  the  ear  of  the  auscultator.  It  is  best  elicited  by 
causing  the  patient  to  say  "  twenty-one,"    "  twenty-two," 


448        PHYSICAL    EXAMINATION    OF    THE    LUNGS. 

"  tweuty-tliree,"  in  his  natural  voice.  It  is,  as  a  rule,  most 
distinct  in  adult  males,  especially  if  the  voice  is  grave  in 
pitch,  but  it  is  subject  to  such  variations,  that  in  the  absence 
of  other  signs  of  disease  little  diagnostic  importance  can  be 
attached  to  it.  It  is  well  to  recollect  also,  that  even  in 
health  it  is  louder  in  most  cases  at  the  apex  of  the  right  lung 
than  of  the  left.  Over  the  spongy  lung  the  vocal  resonance 
is  simply  an  indistinct  buzzing,  but  if  listened  to  over  the 
trachea,  it  is  found  to  be  loud  and  near  the  ear,  every  syl- 
lable is  quite  appreciable  even  when  whispered.  This  is 
almost  identical  with  pectoriloquy,  in  wdaich  the  sounds 
appear  to  be  transmitted  directly  into  the  ear  from  the  chest. 
Over  the  site  of  the  larger  bronchi  the  voice  possesses  a  less 
degree  of  distinctness  and  intensity,  and  to  this  is  applied 
the  term  hronchopJiony. 

In  disease  the  vocal  resonance,  over  what  is  normally  the 
spongy  lung,  may  approximate  to  bronchophony  or  pectorilo- 
quy. The  change  in  the  direction  of  bronchophony  depends 
chiefly  on  consolidation,  and  is  often  present  in  pneumonia, 
phthisis,  and  other  condensations.  Laennec  believed  pec- 
toriloquy (but  only  in  that  degree  which  he  termed  "  perfect 
pectoriloquy")  to  be  pathognomonic  of  cavity  in  the  lung, 
and  no  doubt  it  is  a  frequent  associate  of  this  condition,  and 
a  valuable  fact  in  conjunction  with  other  signs,  but  it  may 
also  be  heard  in  cases  of  consolidation,  such  as  those  men- 
tioned above. 

^gophony  was  the  name  applied  by  Laennec  to  a  pecu- 
liar modification  of  the  vocal  resonance  which  is  high  in 
pitch,  very  tremulous,  and  closely  resembles  the  bleating  of 
a  goat,  or  the  voice  of  Punch  in  the  puppet  show.  It  is 
rarely  found  in  perfection,  but  degrees  of  it  are  not  uncom- 
mon, and  its  most  frequent  site  is  near  the  inferior  angle  of 
the  scapula.  Laennec  thought  it  depended  on  the  interpo- 
sition of  a  thin  stratum  of  fluid  between  the  layers  of  the 
pleura,  but  it  is  also  found  in  the  course  of  pneumonia,  and 
in  inflammatory  thickening  of  the  pleura.  Its  cause  is  still 
a  matter  of  dispute. 

Antophony  is  a  term  used  to  denote  increased  resonance 
of  the  auscultator's  voice  if  he  speaks  while  he  has  his  ear 
applied  to  tlie  patient's  chest.  He  hears  the  tones  of  his 
voice  intensified.  This  phenomenon  is  heard  more  or  less 
in  most  of  the  cases  where  bronchophony  is  developed,  but 
it  is  chiefly  marked  in  cases  of  large  cavity,  especially 
pneumothorax. 


EXAMINATION    OF    THE    NORMAL    HEART.        449 

The  vocal  resonance  may  be  absent  in  certain  cases,  and 
this  is  an  important  fact  if  the  resonance  was  known  to  have 
existed  previously;  or  it  may  be  absent  only  on  one  side  or 
one  part.  This  points  to  some  obstacle  to  the  transmission 
of  the  sound,  chiefly  owing  to  fluid  efi^usion  or  some  obstruc- 
tion in  the  bronchial  tubes.  (For  amphoric  voice  in  pneumo- 
thorax see  page  447.) 

The  vocal  fremitus  is  closely  allied  to  vocal  resonance.  It 
is  the  sensation  communicated  to  the  hand  placed  on  the 
patient's  chest  while  he  speaks.  This  is  also  subject  to 
great  variation,  consistent  with  perfect  health,  but  it  may  be 
stated  as  a  general  rule,  that  conditions  leading  to  increase 
or  diminution  of  the  vocal  resonance  apply  to  vocal  fremitus. 
It  is  thus  generally  increased  in  consolidation  of  the  lung, 
and  diminished  in  pleuritic  eff"usion. 

In  certain  diseased  conditions  of  the  lungs  the  heart's 
sounds  may  be  transmitted  widely  over  the  pulmonary  area. 
This  is  especially  the  case  in  all  forms  of  consolidation,  and 
when  this  transmission  is  to  the  apices  of  the  lungs,  and 
especially  to  the  right,  it  is  jaften  significant  of  phthisical 
consolidation.  The  heart's  sounds  may  be  altered  in  quality 
owing  to  diseased  conditions  in  the  lung,  but  these  will  be 
noticed  under  the  physical  diagnosis  of  the  heart. 


PART  II.— PHYSICAL  EXAMINATION  OF  THE  HEART. 

In  the  physical  examination  of  the  heart  the  same  methods 
of  investigation  are  employed  as  in  the  case  of  the  lungs,  viz., 
Inspection,  Palpation,  Percussion,  and  Auscultation. 

It  is  of  great  importance  for  the  beginner  to  practise  fre- 
quently the 

EXAMINATION  OF  THE  NORMAL  HEART. 

The  first  point  of  importance  for  the  student  to  note  is  the 
contour  of  the  chest-ioall  in  front  of,  and  inclosing  the  organ. 
In  the  healthy  chest  the  left  is  usually  symmetrical  with  the 
right  side,  but,  as  will  afterwards  be  seen,  certain  diseases 
may  cause  alterations  in  respect  of  this  symmetry,  which 
may  have  a  diagnostic  importance.  Having  inspected  the 
precordial  region,  and  having  noted  the  fact  of  any  visible 
pulsation,  whether  diff'used  over  the  cardiac  area,  or  local- 
ized to  the  apex-region,  the  epigastrium,  or  other  part  of  the 

38* 


450      PHYSICAL    EXAMINATION    OF    THE    HEART. 

chest,  the  next  point  to  determine,  if  possible,  is  the  exact 
position  of  the  apex-beat.  In  many  cases  this  corresponds 
■with  a  visible  pulsation  which  will  have  been  noted  in  the 
preliminary  survey,  but  in  not  a  few  instances  no  such  dis- 
tinct pulsation  is  seen,  and  careful  search  by  palpation  must 
be  made  for  the  apex.  In  all  cases,  whether  there  is  a  visi- 
ble apex-beat  or  not,  the  intercostal  spaces  in  the  precordial 
region  should  be  separately  examined  with  the  tips  of  the 
index  and  middle  lingers,  in  order  to  fix  if  possible  the  exact 
spot  at  which  the  apex,  or  rather  the  most  superficial  part  of 
the  left  ventricle,  strikes  the  chest  wall.  The  most  favorable 
opportunity  for  this  is  in  expiration,  when,  by  the  recession 
of  the  lung,  the  heart  approximates  itself  most  closely  to  the 
ribs  ;  but  the  state  of  expiration  must  not  be  long  main- 
tained, otherwise  the  apex-beat  becomes  obscure  from  other 
causes  (see  foot-note,  p.  453). 

In  the  normal  chest,  in  the  recumbent  posture,  the  apex- 
beat  is  usually  found  in  the  fifth  intercostal  space,  slightly 
inside  the  vertical  line  of  the  nipple.  It  is  to  be  remembered, 
however,  that  the  site  of  the  -nipple  varies  to  some  extent 
even  in  males,  and  in  women  its  position  is  ruled  by  the  degree 
of  development  and  laxity  of  the  mamma,  and  so  its  relation 
to  the  apex-beat  is  by  no  means  constant.  The  usual  posi- 
tion of  the  apex-beat  is  as  above  indicated  ;  but  in  not  a  few 
instances,  even  in  healthy  subjects,  no  distinct  impulse  exists 
while  the  patient  is  in  dorsal  decubitus,  and  only  a  compara- 
tively feeble  pulsation  is  felt  in  the  fourth  or  fifth  intercostal 
space.  In  such  a  case  the  patient  should  be  turned  on  his 
left  side  well  round  on  the  face.  This  change  in  posture 
favors  the  gravitation  of  the  heart  to  the  surface  of  the  chest, 
and  to  the  left  side,  so  that  an  apex-beat  that  was  almost 
imperceptible  in  the  recumbent  position  may  become  distinct. 
Under  such  circumstances,  allowance  must  be  made  for  its 
being  carried  more  to  the  left,  but  the  degree  of  this  varies 
in  different  subjects  according  to  the  laxity  of  the  tissues 
which  bind  the  heart.  Percussion  may  assist  in  determining 
to  some  extent  the  site  of  the  apex  as  it  is  usually  found  im- 
mediately inside  the  left  border  of  the  precordial  dulness. 
But  the  student  should  also  use  the  stethoscope  in  aid  of 
palpation  in  determining  this  most  important  fact,  and  it  is 
specially  useful  where  no  tangible  apex-beat  exists.  For  this 
purpose  he  should  auscultate  in  the  apex-region  till  a  spot  is 
found,  over  which  the  first  sound  of  the  heart  has  the  most 
definite  and  superficial  character,  and  this  may  be  assumed 


CARDIAC    PERCrSSION.  451 

to  be  the  point  at  which  the  wall  of  the  left  ventricle  comes 
nearest  to  the  surface. 

Having  determined  as  nearly  as  posible  the  position  of  the 
apex-beat,  it  should  be  marked  (with  ink  or  otherwise),  and 
the  next  step  is  to  appreciate  thoroughly  the  nature  of  the 
impulse.  This  can  be  done  either  with  the  tips  of  the  fingers 
or  the  ball  of  the  thumb,  the  former,  however,  yielding  the 
more  accurate  results.  In  healthy  subjects  in  whom  a  tan- 
gible apex-beat  exists,  it  is  limited  in  area.  weD-defined,  and 
punctuate,  and  in  those  in  whom  it  is  not  present  in  the  re- 
cumbent posture,  but  is  developed  when  they  are  laid  over 
on  the  left  side,  it  presents  similar  characters.  Changes  in 
neighboring  organs  may  have  so  altered  the  relations  of  the 
apex  as  to  obscure  its  impulse  in  all  positions,  and  such  a 
condition  is  to  be  noted,  but  it  does  not  necessarily  indicate 
disease  of  the  heart.  A  punctuate  apex-beat  may  also  be 
wanting  in  healthy  subjects  froin  the  fact  that  the  impulse 
is  delivered  against  a  rib  and  does  not  reach  an  intercostal 
space.  In  the  strictly  healthy  subject  no  considerable  im- 
pulse exists  over  the  right  ventricle,  but  a  degree  of  this  can 
be  educed  by  sudden  exertion,  and  it  may  be  discriminated 
from  the  apex-beat.  This  impulse  or  heave  is  best  appre- 
ciated by  the  ball  of  the  thumb  or  palm  of  the  hand  placed 
over  the  region  of  the  right  ventricle.  It  can  also  be  well 
appreciated  by  the  direct  application  of  the  ear  when  the 
impulse  is  communicated  to  the  head.  The  student  should 
notice  this  impulse  carefully,  as  in  some  diseased  conditions 
it  is  of  much  diagnostic  value.  In  widely  diffused  impulse 
the  point  furthest  to  the  left,  giving  a  distinct  and  direct 
impact,  is  to  be  regarded  as  the  most  probable  site  of  the 
apex,  but  it  does  not  necessarily  follow  in  such  cases  that  the 
real  apex  of  the  left  ventricle  produces  any  sensible  and 
separate  impact  at  all. 

Percussion  of  the  heart  is  the  next  step  in  the  examina- 
tion. In  women  in  whom  the  mamma  is  large  and  flabbv  it 
should  be  drawn  up  or  to  one  side  wliile  the  percussion  is 
being  followed  out.  The  area  of  precordial  duluess  will 
vary  somewhat  according  to  the  strength  of  the  percussing 
stroke.  If  the  deep  or  relative  percussion  dulness  is  wanted, 
a  comparatively  strong  stroke  is  necessary,  and  the  percus- 
sion should  be  made  as  far  as  possible  during  expiration, 
while  the  heart  is  most  uncovered.  If,  however,  the  super- 
ficial or  absolute  dulness  is  required,  the  lightest  stroke 
should  be  employed,  in  order  to  determine   accurately  only 


452      PHYSICAL    EXAMINATION    OF    THE    HEART. 

that  part  of  tlie  heart  which  is  most  superficiaL  The  stu- 
dent shoukl  familiarize  himself  with  both  methods,  but  in 
the  description  here  given  the  latter  is  the  one  chiefly  in 
view.  It  is  best  to  percuss  from  the  clear  area  of  lung  on  to 
the    dull    area  of   heart,  and    commencins   with    the    ri"rht 


Pig.  69.- 


-Area  of  Knrmal  Percuxsion-dulness  of  Heart,  Liver,  and  Spleen. 
(Slightly  modified  from  Weil.) 


border,  the  student  should  appreciate  thoroughly  the  clear 
note  over  the  right  lung  and  then  percuss  towards  the  middle 
line,  noting  the  point  at  which  the  clear  pulmonaiy  note 
become?  modified.  Having  percussed  the  whole  of  the  right 
border  in  this  manner  he  should  proceed  to  the  left,  to  which 
the  position  of  the  apex-beat  will  afford  a  guide.    To  delimit 


CHANGES    IN    APEX-BEAT.  453 

tlie  upper  border,  percussion  is  to  be  made  from  the  left  intra- 
clavicular  region  downwards.  The  lower  border  of  cardiac 
dulness  cannot,  as  a  rule,  be  separated  from  that  of  liver. 
It  is  useful  to  indicate  these  limits  of  percussion-dulness  by 
marking  them  -with  ink  or  crayon.  The  right  border  of  the 
dulness  to  superficial  percussion  will  be  found  usually  to 
coincide  pretty  exactly  with  the  mesial  line,  while  with  deep 
percussion  it  will  pass  to  the  right  of  that  line  from  one  inch 
and  a  half  to  two  inches.  The  left  border,  as  a  rule,  coin- 
cides with  a  line  about  half  an  inch  outside  the  apex-beat, 
and  so  corresponding  nearly  with  the  vertical  line  of-  the 
nipple.  The  upper  margin  of  dulness  is  usually  near  the 
lower  border  of  the  third  rib,  and  it  slopes  downw-ard  to 
join  the  left  margin  (see  Diagram,  No.  69).  The  transverse 
measurement  of  this  area  to  superficial  percussion  in  the 
healthy  chest  may  be  stated  approximately  at  from  three  to 
four  inches  in  the  adult  male.  In  women  it  is  less,  and  it 
will  vary  according  to  the  build  and  stature  of  the  subject. 
While  performing  the  percussion  attention  should  be  given 
to  the  sense  of  resistance  to  the  percussing  stroke,  as  an 
increase  in  this  may  assist  the  diagnosis.  In  many  instances, 
however,  the  delimitation  of  the  cardiac  dulness  is  interfered 
with  by  the  occurrence  of  consolidation  in  either  lung  in  close 
proximity  to  the  heart,  or  by  the  presence  of  fluid  in  the 
pleurae. 

The  Sounds  of  the  heart  are  discussed  at  p.  461. 

CHANGES  IN  THE  APEX-BEAT— ABNORMAL  PULSATIONS. 

77<e  apex-heat  may  become  inapjireciahle  or  at  least  much 
obscured.  This  is  especially  apt  to  occur  in  cases  of  fluid 
effusion  into  the  pericai'dium,  or  from  bulging  of  the  anterior 
margins  of  the  lung  in  emphysema.  Again,  if  the  right 
ventricle  is  much  dilated  it  pushes  the  left  aside,  hinders  it 
from  reaching  the  surface,  and  so  no  punctuate  apex-beat  is 
present,^     In  extensive  adhesion  of  the  pericardium  also, 

1  Apart  from  diseased  conditions  altogether,  a  very  simple  experi- 
ment, wliich  any  one  can  make  on  himself,  will  demonstrate  the 
effect  which  a  distended  right  ventricle  has  on  the  apex-beat. 
When  lying  in  an  easy  xjosition  a  finger  is  put  on  the  apex-beat, 
and  its  character  carefully  noted,  while  with  the  other  hand  the 
pulse  of  some  of  the  arteries  is  felt.  Respiration  is  then  simply 
suspended  without  any  deep  preliminary  inspiration.  As  the  sense 
of  suffocation  approaches,  the  apex-beat  grows  gradually  more  in- 
distinct,  and  may  even  disappear,  while  the  heave  of  the  right 


454      PHYSICAL    EXAMINATION    OF    THE    HEART. 

there  is  often  no  distinct  apex-impulse  forward,  but  rather 
a  systolic  retraction  of  one  or  two  of  the  intercostal  spaces  in 
the  vicinity  of  the  apex-region,  while  at  the  same  time  the 
heart  has  a  jogging  or  tumbling  action.  The  absence  or 
want  of  precision  of  the  apex-beat  may  thus  indicate  disease 
either  of  the  heart  itself  or  of  some  of  the  neiorhboring 
organs. 

The  apex-impiilse  may  he  exaggerated.  This  is  genei'ally 
the  case  in  hypertrophy  of  the  left  ventricle,  in  which  also  it 
is  usually  displaced  downwards  and  to  the  left. 

The  apex-beat  is  often  displaced.  It  may  be  found  dis- 
placed doicmvards  and  toxoards  the  left.,  so  as  to  be  felt  in 
the  6th,  7th,  or  8th  intercostal  space,  several  inches  outside 
the  nipple  line.  Under  such  circumstances  the  impulse  is 
usually  nuich  increased  in  intensity,  and  so  wide-spread  as 
to  be  visible  in  two  or  three  intercostal  spaces.  This  is 
usually  found  in  hypertrophy,  chiefly  involving  the  left  ven- 
tricle. The  apex-beat  may  come  to  be  displaced  upwards., 
owing  to  pressure  on  the  diaphragm  of  abdominal  tumors, 
ovarian  disease,  ascites,  enlargement  of  liver,  &c.,  or  it  may 
be  dragged  upwards  by  a  shrinking  of  the  left  lung,  as  in 
phthisis,  with  contracting  cavities  in  the  apex,  or  from  re- 
traction of  one  side  of  the  chest  after  the  absorption  of  an 
effusion.  In  considerable  pericardial  effusion  the  apex-beat 
is  apt  to  be  I'aised,  and  the  same  is  said  to  occur  in  cases  of 
adherent  pericardium.  It  may  be  found  displaced  either  to 
the  right  or  left  by  fluid  or  air  in  the  pleuras  (Hydrothorax 
or  Pneumothorax).  The  displacement  is  much  greater  when 
the  effusion  is  in  the  left  pleura,  and,  if  it  is  extreme,  the 
heart  may  be  found  beating  under  the  right  nipple.  This 
condition  has  been  called  by  the  late  Dr.  Stokes,  Dexio- 
cardia  (see  Fig.  73).  The  impulse,  however,  which  is  felt  in 
such  a  case  is  not  from  the  apex  of  the  left  ventricle,  but 
from  some  part  of  the  right.  The  heart  may  remain  dis- 
placed after  the  effusion  disappears,  through  the  influence  of 

ventricle  becomes  very  marked.  The  pulse,  however,  is  not  afl'ected 
to  anj  extent,  except  j^erhaps  being  a  little  smaller,  and  this  shows 
that  the  left  ventricle  is  still  contracting  quite  efficiently  although 
the  apex-imjjulse  has  become  obscure  ;  owing  to  the  repletion  of 
the  right  ventricle  the  left  is,  as  it  were,  thrown  behind  and  can- 
not reach  the  chest  wall.  When  respiration  is  resumed  the  apex- 
beat  becomes  apparent  at  once.  These  conditions  are  quite  inde- 
pendent of  the  expansion  of  the  lung,  being  equally  appreciable  in 
inspiration  or  expiration. 


ABNORMAL    PULSATIONS.  455 

adhesions.  Changes  in  the  character  of  the  apex-impulse 
are  also  to  be  noted.  It  may  become  unduly  strong  and 
heaving  in  hypertrophy,  or  weak  in  cases  of  dilatation  and 
fatty  degeneration.  Its  regularity,  or  the  reverse,  in  rliythm 
and  force,  must  also  be  attended  to. 

Centres,  other  than  the  apex-beat,  may  become  developed 
in  diseased  conditions.  In  certain  cases,  coincidently  with 
a  want  of  distinct  apex-beat,  there  is  an  undue  develoi)ment 
of  the  impulse  or  heave  of  the  right  ventricle.  This  is  espe- 
cially the  case  in  dilatation  or  hypertrophy  of  the  riglit  side 
of  the  heart.  A  diffused  impulse  is  then  appreciable  over 
the  region  of  the  right  ventricle,  which  is  often  propagated 
into  the  epigastrium,  through  the  left  lobe  of  the  liver,  in 
the  form  of  a  wide-spread  pulsation,  and  in  certain  cases  of 
displacement  of  the  heart,  even  a  more  direct  impulse  may 
be  felt.  As  this  epigastric  pulsation  is  always  important, 
it  should  be  sought  for,  not  only  by  placing  the  flat  of  the 
hand  over  the  pit  of  tlie  stomach,  but  also  by  inserting  the 
tips  of  the  fingers  under  the  costal  cartilages  in  the  direction 
of  the  heart.  This  epigastric  pulsation  from  the  action  of 
the  heart  must  be  distinguished  from  a  pulsation  communi- 
cated from  the  aorta,  which  is  felt  under  certain  conditions 
in  the  same  region.  The  aortic  pulsation  can  usually  be 
traced  along  the  vessel  in  the  abdomen,  not  merely  as  a  pul- 
sating tumor,  and,  by  careful  attention  to  its  rhythm,  it  will 
be  found  to  succeed  the  cardiac  systole.  This  "  throbbing 
aorta"  is  a  frequent  fact  in  anasmic  or  nervous  conditions 
(see  p.  263).  Aneurism  of  the  abdominal  aorta,  or  of  some 
of  its  branches,  may  also  give  rise  to  pulsation  in  the  epigas- 
trium, but  other  signs  will  usually  guide  the  diagnosis. 

When  the  base  of  the  heart  is  uncovered,  owing  to  retrac- 
tion of  the  edge  of  the  left  lung,  as  in  phthisis  pulmonalis, 
the  roots  of  the  great  vessels,  and  especially  of  the  pulmonary 
artery,  as  it  is  most  superficial,  are  exposed,  and  as  it  usually 
happens  in  such  cases  that  the  patient  is  much  emaciated,  a 
pulsation  which  corresponds  witli  the  expansion  of  the  pul- 
monary artery  can  sometimes  be  felt  and  even  seen.  It  is 
situated  about  the  third  left  intercostal  space,  near  the 
margin  of  the  sternum,  is  very  restricted  in  its  area,  and,  in 
addition  to  the  impulse,  the  finger  is  conscious  of  its  being 
succeeded  by  a  snap  and  sudden  recoil,  coincident  with  the 
closure  of  the  sigmoid  valves.  In  rare  instances,  pulsation 
from  the  auricle  exists  in  this  situation,  but  the  impulse  in 
such  a  case  precedes  the  apex-beat,  and  is  succeeded  by  no 


456      PHYSICAL    EXAMINATION    OF    THE    HEART. 

snap.  Simultaneous  tracings  of  the  cardiac  apex-beat  and 
the  abnormal  pulsation  in  such  cases  may  be  taken  with  the 
cardiograph,  and  will  at  once  resolve  any  difficulties  that 
may  arise  as  to  its  being  due  to  auricle  or  pulmonary  artery. 
The  aorta  is  too  deeply  seated  to  give  any  definite  impulse 
externally  in  the  normal  conditions,  but  when  aneurismal 
disease  of  its  thoracic  portion  exists  a  pulsation  may  be  pro- 
duced which  can,  as  a  rule,  be  quite  easily  separated  from 
that  of  the  heart  (see  p.  475). 

Pulsation  in  the  vessels  of  the  neck.  The  jugular  fossa 
should  be  explored  by  inserting  the  tips  of  the  fingers  down 
behind  the  sternum,  the  patient  being  directed  to  bend  the 
head  forwards,  so  as  to  relax  the  tissues.  Undue  pulsation 
somtimes  associated  with  the  sense  of  resistance  or  tumor, 
chiefly  due  to  aneurism,  is  often  met  with  in  this  situation. 
The  trachea  may  be  found  displaced  somewhat  backward,  or 
to  either  side  in  such  cases.  The  state  of  the  jugular  veins 
is  also  to  be  noted,  pulsation  in  them  being  a  frequent  asso- 
ciate of  valvular  diseases  of  the  right  side  of  the  heart. 
Such  pulsation,  however,  is  not  necessarily  a  morbid  fact ; 
it  merely  indicates  regurgitation  of  blood  back  into  the  veins, 
the  valves  at  the  root  of  the  neck  being  incompetent.  This 
may  occur  in  perfect  health,  though  usually  only  in  a  slight 
degree,  without  any  distension  or  other  abnormal  symptom, 
from  the  impulse  of  the  auricle  (perhajjs  also  of  the  right 
ventricle)  being  transmitted  directly  through  congenitally 
imperfect  valvular  mechanism,  which  is  productive  of  no 
sensible  inconvenience.  In  some  instances,  although  there 
is  no  actual  pulsation  in  the  vein,  it  receives  a  movement 
from  the  artery  lying  underneath  it,  so  as  to  simulate  this : 
the  way  to  solve  the  difficulty  is  by  pressing  very  lightly  on 
the  vein  at  the  root  of  the  neck,  and  so  occluding  it,  and  if 
under  these  circumstances  the  pulsation  ceases,  the  inference 
is  that  the  action  is  in  the  vein,  while  if  it  continues  it  is 
most  probably  due  to  the  heave  of  the  carotid.  The  pulsa- 
tion also  in  the  veins  of  the  neck  can  usually  be  recognized 
as  diflferent  in  character  from  a  transmitted  arterial  impulse, 
being,  as  a  rule,  much  more  wavy.  Retraction  of  the  veins 
of  the  neck  during  the  cardiac  diastole  should  be  looked  for, 
as  it  is  said  to  occur  sometimes  in  cases  of  adherent  peri- 
cardium. Undue  pulsation  in  the  arteries  of  the  neck  exists 
in  exophthalmic  goitre,  in  some  cases  of  anaemic  palpitation, 
and  in  aortic  insufficiency,  where  the  visible  pulsation  is 
often  a  verv  marked  feature. 


CHAXGES    IN'    CARDIAC    DrLNESS. 


45' 


CHANGES  IX  THE  AEEA  OF  PEECORDIAL  DULXESS. 

The  area  of  precordial  dulness  mar  be  increased,  dimin- 
ished, or  displaced.  Decrease  in  its  area  is  generally  due, 
not  to  disease  of  the  heart  itself,  but  to  changes  in  the  lungs, 
and  especially  to  emphysema,  in  which  the  anterior  margins 
of  the  lung  may  become  so  distended  as  to  mask  the  cardiac 
dulness  to  a  greater  or  less  extent.  (.See  Fig.  84,  p.  486.) 
In  emaciating  diseases,  however,  the  heart  participates  in 
the  general  atrophy,  and  this  may  lead  to  some  decrease  iii 
the  precordial  dulness. 


Fig.  TO. — Cardiac  Dulness  increased  from  Hypertrophy  of  Loth  Tentricles. 

But  increase  in  this  area  is  much  more  frequent.      If  the 

increase  is  towards  the  left  side  and  downwards,  and  coincides 

with  a  strong  and  somewhat  diffused  apex-beat  in  the  sixth 

or  seventh  interspace,  or  much  to  the  left  of  its  uonnal  site, 

39 


458      PHYSICAL    EXAMINATION    OF    THE    HEART. 


it  most  likely  indicates  hypertrophy  of  the  left  ventricle.  If 
on  the  other  hand,  the  dulness  extends  chiefly  to  the  right, 
the  presumption  is  that  the  right  ventricle  is  the  seat  of  hy- 
pertrophy or  dilatation,  and  this  may  be  corroborated  by  the 
occurrence  of  a  well  marked  heaving  action  over  the  right 
ventricle,  by  an  ill-defined  apex-beat,  and  by  the  presence  of 
pulsation  in  the  epigastrium.  If  the  dulness  is  increased 
pretty  equally  both  to  right  and  left,  while  the  upper  margin 
maintains  its  normal  position,  hypertrophy  or  dilatation  of 
both  cavities  may  be  suspected  (see  Fig.  70);  but  if  with 
lateral  extension  there  is  a  conical  prolongation  of  the  dulness 
up  in  the  direction  of  the  first  rib,  there  is  ground  for  sus- 
pecting effusion  into  the  pericardium.  (See  Fig.  71.)  In 
all  these  cases  there  m;iy  be  a  degree  of  vaulting  in  the  pre- 
cordial region,  but  it  is  usually  most  marked  in  pericardial 
effusion,  in  which  the  percussion  resistance  is  also  greatly  in- 
creased. Apparent  increase  in  the  dulness  may  arise  from 
tujnors,  aneurismal,  cancerous,  or  glandular,  situated  in  the 
mediastinum,  or  from  effusions  into  the  pleurae,  or  even  from 
limited  consolidations  of  the  lung  in  the  immediate  vicinity 
of  the  heart.     The  diagnosis  of  aneurism  may  be  made  from 

the  fact  that  the  abnor- 
mal area  of  dull  percus- 
sion is  usually  situated 
at  the  base  of  the  heart, 
often  under  the  manu- 
brium sterni  ;  it  coin- 
cides in  situation  with 
the  aorta,  and  is  some- 
times joined  to  the  car- 
diac dulness  by  only  a 
narrow  neck ;  a  pulsation 
se|)arable  from  that  of 
the  heart  is  often  present 
over  it,  sometimes  ac- 
companied with  thrill, 
and  the  heart's  sounds 
are  often  changed  in  qual- 
ity bver  the  dull  area, 
and  sometimes  associ- 
ated with  murmur.  The 
diagnosis  in  the  other 
conditions  mentioned  may  be  assisted  by  the  fact  that  the 
cardiac  sounds  are  normal  in  character,  not  coextensive  with 


FifT.  71. — Percussion-dulness  in  P'ricar- 
dini  Effusion  :  the  lower  and  left  marglas 
aro  undefined,  owing  to  their  beini;  insepara- 
ble from  the  dull  percussion  of  the  abdomen 
and  of  the  left  pleuia.     (Gairduer.) 


CARDIAC    TREMOR    OR    THRTLL.  459 

the  dull  area  and  there  is  not  the  heavinjif  impulse  that  miglit 
be  expected  were  the  extension  due  to  dilatation  or  hypertro- 
phy of  the  heart  itself.  Symptoms  will  also  afford  valuable, 
means  of  diasjnosis. 


Fig.  72. — Displacement  of  mediastinum,  heart,  ani  liver  from  pneumotliorax  of 
the  right  aide.     (Weil.) 

Displacement  of  the  area  of  cardiac  dulness  either  to  the 
right  or  left  may  be  due  to  pleural  effusions  of  fluid  or  air, 
the  displacement  being  always  most  marked  when  the  left 
pleura  is  the  seat  of  the  disease.  (See  Figs.  72  and  73.) 
Tumors  in  the  thorax  may  displace  the  precordial  dulness  in 
almost  any  direction.     A  certain  amount  of  displacement  of 


460      PHYSICAL    EXAMINATION    OP    THE    HEART. 

the  cardiac  dulness  is  of  habitual  occurrence  in  emphysema 
of  the  lung,  associated  usually  with  some  diminution  of  its 
extent  also.     (See  Fig.  84,  p.  486.) 


Fig.  73  — Displacement  of  mediastinum,  heart,  and  l<'ft  lobe  of  lis-er  from 
pleuritic  effui-ion  on  the  left  side:  the  shading  indicates  the  extent  of  dull  per- 
cussion. 

CARDIAC  TREMOR  OR  THRILL. 

In  the  palpation  of  the  heart  there  is  sometimes  conveyed 
to  the  hand  along  with  the  impulse  a  sense  of  tremor  or 
thrill — "purring  tremor."  It  is  most  frequently  associated 
with  valvular  disease  either  aortic  or  mitral,  and  is  quite 
distinct  in  its  production  from  the  sensation  which  is  some- 
times felt  over  the  precordial  region  in  pericarditis,  from  the 
rubbing  of  the  rougliened  pericardial  surfaces  on  each  other. 


SOUNDS    OF    THE    HEART.  461 

This  latter,  when  typical,  has  a  rubbing,  grating  ch?,racter, 
and  does  not  as  a  rule  possess  the  fixity  as  regards  site  and 
rhythm  of  endocardial  thrills.  The  most  usual  sites  of 
tremor  are  the  apex  and  the  base.  When  limited  to  the 
apex  it  is  very  characteristic  of  constriction  or  roughening  of 
the  mitral  orifice,  provided  it  can  be  felt  immediately  to 
precede  the  apex-beat.  It  coincides  in  fact  with  a  presys- 
tolic murmur.  In  not  a  few  instances,  however,  thrill  in 
the  apex-region  coincides  with  ventricular  contraction,  and 
is  due  to  regurgitation  through  the  mitral"  orifice.  When 
felt  at  the  base,  thrill  is  usually  associated  with  disease 
(chiefly  obstructive)  of  the  aortic  valves,  but  this  is  not 
invariably  the  case,  as  tremor  sometimes  exists  in  aneurism 
of  the  first  part  of  the  aorta  apart  from  any  valvular  lesion. 
Other  conditions  afterwards  to  be  indicated  will  guide  the 
diagnosis  in  all  these  cases. 

SOUNDS  OF  THE  HEART,  NORMAL  AND  ABNORMAL- 

In  auscultating  over  the  heart  the  student  will  recognize 
two  sounds  which  differ  in  their  characters  and  sites  of  in- 
tensity. They  are  called  the  first  and  the  second  sounds. 
The  first  sound,  which  coincides  with  the  ventricular  con- 
traction and  the  apex-beat,  and  immediately  precedes  the 
pulse  in  the  neck,  is  dull,  prolonged,  and  somewhat  distant. 
The  second  sound  coincides  with  no  impulse,  is  clearer, 
sharper,  and  more  defined,  and  agrees  in  point  of  time  with 
the  closure  of  the  sigmoid  valves  of  the  aorta  and  pulmonary 
artery.  The  characters  of  the  two  have  been  represented  by 
the  syllables  "  Lubb  Tup."  The  first  is  heard  with  greatest 
intensity  over  the  apex-region,  while  the  second  predomi- 
nates over  the  base  of  the  heart.  Skoda  indicates  the  inten- 
sity of  the  two  sounds  as  heard  at  the  apex  and  base,  by 
saying  that  at  the  apex  they  form  a  Trochee — liibb  tuj — • 
and  at  the  base  an  Iambus — lubb  tiip.  In  a  slowly  acting 
heart  there  is  usually  no  difficulty  in  distinguishing  the 
sounds,  which  are  defined  not  only  by  the  characters  above 
indicated,  but  also  by  the  fact  that  the  interval  between  the 
first  sound  and  the  second  is  much  shorter  than  that  between 
the  second  and  the  first,  the  diastole  or  long  pause  of  the 
heart  as  it  is  called  intervening.  The  following  diagram 
(Fig.  74),  indicates  approximately  the  relations  which  the 
various  periods  in  a  complete  cardiac  revolution  bear  to  each 
other.     When,  however,  the  heart  is  acting  rapidlv  the  in- 

39* 


462       PHYSICAL    EXAMINATION    OF    THE    HEART. 

crease  is  chiefly  at  the  expense  of  the  long  pause,  and  then 
it  may  be  a  matter  of  ditficulty  to  determine  which  is  the 
first  and  which  is  the  second  sound  ;  and  tliis  all  the  more 
so  if  either  sound  is  so  altered  in  character  as  to  approximate 
to  its  fellow.  The  double  stethoscope  will,  as  a  rule,  how- 
ever, resolve  this  doubt,  the  one  bell  being  placed  over  the 
apex  and  the  other  over  the  base. 


ZndsOUNO 


j-.g.  74. — Diagram  of  hean's  Actiun.i     iGairdner.) 

Both  sounds  are  complex  inasmuch  a?  the  tlrst  coincides 
with  the  contraction  of  the  two  ventricles  and  the  second 
with  the  closure  of  the  sigmoid  valves  of  the  aorta  and  pul- 
monary artery.  That  part  of  the  first  sound  due  to  the  left 
ventricle  is  heard  with  greatest  distinctness  in  the  apex- 
reo-ion,  wliile  that   from  the  right  side  of  the  heart  is  most 


'  This  figure  is  retained  (after  considerable  investigation)  with- 
out serious  modification  :  it  represents  ^In  a  diagramatic  form  the 
relation  of  the  different  portions  of  a  cardiac  revolution  to  each 
other  :  but  it  does  not  aim  at  accuracy  as  regards  the  exact  dura- 
tion of  the  sounds,  which  are  not  as  yet  capable  of  being  measured 
with  precision. 


ALTERATIONS    IN    THE    HEART's    SOUNDS.         463 

intense  over  the  right  ventricle  near  the  sternum.  The 
aortic  element  of"  the  second  sound  is  best  communicated  to 
a  point  at  the  junction  of  the  second  right  costal  cartilage 
with  the  sternum,  this  being  often  called  the  "  aortic  carti- 
lage." The  pulmonic  second  sound  is  best  heard  near  the 
junction  of  the  third  left  costal  cartilage  with  the  sternum. 
In  health,  as  a  rule,  the  sounds  at  the  apex  and  aorta  pre- 
dominate over  those  of  the  right  side  of  the  heart.  Some 
assistance  is  also  obtained  from  considering  the  relative  in- 
tensity, in  various  circumstances,  of  the  sounds  as  heard 
over  the  carotid  and  subclavian  arteries,  where  the  second 
sound  may  usually  be  regarded  as  identical  with  that  pro- 
duced by  the  closure  of  the  aortic  valves.  But  much  care  is 
necessary  in  founding  conclusions  on  the  above  data. 

The  sounds  of  the  heart  may  become  (1)  altered  in  char- 
acter; (2)  reduplicated;  (3)  associated  with  or  replaced  by 
murmurs. 

I.    Alterations    in    Character    of    the    Heart's 

Sounds In  many  exhausting  diseases  the  sounds  are  apt 

to  become  feeble,  and  in  the  later  stages  of  certain  fevers, 
notably  typhus,  the  first  sound  is  especially  weakened,  and 
in  extreme  cases  almost  suppressed,  while  the  second  may 
remain  tolerably  clear  and  distinct.  Fatty  degeneration  or 
infiltration  of  the  muscular  fibre  of  the  heart  naturally  leads 
to  the  same  result.  In  dilatation  also  the  first  sound  fails 
in  intensity  and  duration,  and  in  some  cases  it  becomes 
clearer  than  normal,  approaching  the  quality  of  the  second 
sound.  Strengthening  of  the  cardiac  sounds  is,  as  a  rule, 
due  to  hypertrophy.  This  is  especially  the  case  with  regard 
to  the  first,  which  becomes  dull,  prolonged,  and  booming  in 
character.  If  this  change  is  most  marked  in  the  apex- 
region,  the  presumption  is  that  the  left  ventricle  is  hyper- 
trophied,  while  if  it  is  present  over  the  right  ventricle  it 
usually  points  to  that  cavity  as  the  seat  of  the  change.  In 
each  case  the  second  sound  is  unduly  accentuated,  the  alter- 
ation being  recognizable  as  over  the  aorta  or  pulmonary 
artery,  according  to  the  cause  of  it.  But  the  second  sound 
maybe  accentuated  and  deepened  in  tone,  becoming  "•clunk- 
ing" in  fact,  apart  from  hypertrophy  of  the  ventricles.  This 
may  be  present  over  the  aortic  cartilage  in  cases  of  high 
arterial  tension  in  the  systemic  circulation,  or  in  dilatation 
of  the  arch  of  the  aorta,  or  when  the  aorta  has  lost  its  elas- 
ticity from  degenerative  changes.  In  all  such  cases  the 
deepened  tone  is  usually  transmitted  into  the  vessels  in  the 


4fi4      PHYSICAL    EXAMINATION    OF    THE    HEART. 

neck.  Over  the  pulmonary  artery  the  second  sound  is  ac- 
centuated in  conditions  which  present  an  obstacle  to  the 
free  passage  qf  blood  through  the  lungs.  This  change  is 
met  with  in  pneumonia,  and  is  often  a  marked  feature  in 
cases  of  obstruction  or  regurgitation  at  the  mitral  orifice. 
In  certain  cases,  as  in  retraction  of  the  upper  lobe  of  the 
left  lung  from  phthisis,  the  second  pulmonic  sound  may  ap- 
pear to  be  morbidly  accentuated  when  in  reality  it  is  simply 
brought  near  the  ear  by  having  lost  its  covering  of  lung.  In 
most  of  these  instances,  however,  pulsation,  both  visible  and 
tangible,  is  present  over  the  artery,  and  the  snap  of  the 
closure  of  the  valve  is  often  communicated  to  tlie  hand. 
These  conditions  will  help  to  guide  the  diagnosis.  (See 
p.  455.) 

AVhen  large  air-filled  cavities  are  in  closi^  proximity  to  the 
heart  the  sounds  may  take  on  a  hollow,  ringing,  metallic 
quality  of  the  nature  of  an  echo.  The  first  sound  is  most 
frequently  so  affected,  the  causes  being  large  pulmonary 
cavities,  pneumothorax,  or  an  over-distended  stomach. 

II.  Reduplication  of  the  Heart's  Sounds  arises  from 
a  splitting  up  of  one  or  other  sound  into  its  component  ele- 
ments. Either  sound  may  be  reduplicated,  and  there  is  then 
produced  a  galloping  or  cantering  action  indicated  by  the 
syllables  "  rat-ta-tat."  The  clinical  significance  of  this  fact 
is  not  very  clear.  It  occurs  at  times  in  heaJthy  subjects : 
and  it  will  be  sufficient  for  the  student  to  note  that,  if  it  is 
best  heard  anywhere  over  the  ventricular  area,  it  is  probably 
tlie  first  sound  which  is  resolved  into  its  component  elements, 
while,  if  over  the  base,  it  is  the  second.  Any  condition 
which  increases  the  tension  either  in  the  systemic  or  pul- 
monic circulation  may  predispose  to  reduplication.  It  is 
certainly  a  frequent  fact  in  cases  of  Bright's  disease,  espe- 
cially in  the  granuhir  form  (chronic  Bright's  disease),  but  it 
is  also  not  infrequent  in  the  acute  disorder.  Reduplication 
may  be  complete,  with  the  two  elements  of  the  sound  quite 
distinct  ;  or  incomplete,  wLere  there  is  no  distinct  interval, 
the  sound  appearing  only  lengthened  and  slurred  ("  turnip"). 

III.  Cardiac  Murmurs The  sounds  of  the  heart  may 

be  associated  with  or  replaced  by  murmurs.  The  two  most 
inqjortant  facts  to  determine  about  these  are  (A)  Their 
Rhythm,  and  (B)  Their  Site,  or  Area  of  distribution.  As 
the  great  majority  of  murmurs  are  valvular  in  origin,  it  is 
on,  the  whole  a  good  rule  to  try  all  murmurs  which  require 
detailed  investigation  by  the  tests  of  the  valvular  murmurs 
before  2.roceed!ng  to  any  other. 


RHYTHM    OP    CARDIAC    MURMURS.  465 


A.— RHYTHM  OF  CARDIAC  MURMURS. 

What  has  to  be  considered  under  this  head  is  the  relation 
of  a  murmur  to  the  diiFerent  physiological  acts  which  consti- 
tute a  complete  cardiac  revolution,  viz.,  the  contraction,  dila- 
tation, and  rest  of  each  of  the  cavities  (see  Fig.  74,  p.  462). 
The  murmur  has  to  be  defined  as  occurring  during  this  or 
that  portion  of  the  lieart's  action,  or  during  the  pause  which 
intervenes  between  the  periods  of  activity.  To  do  this  it  is 
necessary  to  watch  carefully  its  relation  to  the  normal  sounds, 
to  the  impulse,  and  to  all  the  other  appreciable  phenomena 
which  attend  upon  the  action  of  the  heart. 

All  valvular  murmurs  (apart  from  those  of  complex  origin) 
have  one  of  three  relations  to  the  sounds  and  impulse  of  the 
heart. 

(1)  The  murmur  'precedes  and  runs  up  to  the  first  sound, 
ending  at  the  moment  of  this  sound  and  of  the  beat  of  the 
apex.  In  this  case  the  murmur  is  synchronous  with  the  con- 
traction of  the  auricles,  and  is  called  Auricular-Systolic,^  or 
by  some  Presystolic  (from  its  preceding  the  systole  of  the 
ventricle).  The  interpretation  of  such  a  murmur  depends 
on  its  occurring  only  when  Mood  is  being  expelled  from  an 
auricle,  and  when  the  ventricle  is  still  passive.  With  very 
rare  exceptions  such  a  murmur  depends  upon  constriction  of 
the  auriculo-ventricular  orifices  and  consequent  interruption 
to  the  flow  of  blood  out  of  the  auricle  during  its  contraction. 
It  is  thus  said  to  be  a  direct  or  onward  murmur,  and  is  usu- 
ally very  rough  in  character,  and  often  accompanied  by  a 
thrill  (see  p.  459). 

The  Auricular-Systolic  murmur  may  merely  precede  the 
first  sound,  i.  e.,  it  may  follow  the  pause  of  the  heart's  action, 
or  it  may  appear  to  be  prolonged  out  of  or  even  quite  through 

'  The  terms  here  applied  to  murmurs,  viz.,  "  Auricular-Systolic" 
(A.S.),  "Ventricular-Systolic"  (V.  S.),  and  "  Ventricular-Dias- 
tolic"  (V.  D.),  have  become  the  habitual  nomenclature  in  the 
Glasgow  School,  and  what  is  meant  by  calling  a  murmur,  a  thrill, 
or  other  phenomenon,  "A.S.,"  "  V.  S.,"  or  "V.D.,"is  that  it 
coincides  in  point  of  rhythm  or  time  with  one  or  other  of  the  periods 
of  the  heart's  action,  which  is  thus  exactly  expressed  (see  Fig.  74). 
The  period  of  auricular  systole  had  no  definite  place  assigned  to  it 
in  any  scheme  prior  to  Dr.  Gairdner's  ;  the  old  term  "Presystolic," 
as  applied  to  a  murmur,  being  vague  and  giving  no  hint  as  to  its 
coincidence  with  the  systole  of  the  auricle.  The  terms  can  be  ap- 
plied to  all  kinds  of  murmurs,  indicating  as  they  do  simply  the 
exact  rhythm  apart  from  any  considerations  of  causation.  - 


466      PHYSICAL    EXAMINATION    OF    THE    HEART. 

it,  tlie  period  of  rest  being  in  this  last  case  necessarily  asso- 
ciated with  a  degree  of  the  ventricular-diastolic  murmur 
presently  to  be  described  (below).  Its  essential  character, 
however,  is  preserved  in  every  case  as  above  defined  and  as 
represented  in  the  diagram  (Fig.  75).  For  the  sake  of 
brevity  it  is  sometimes  named  "  A.S."  (Auricular-Systolic). 


Fig.  75.     (Gairdaer.) 

(2)  The  murmur  follows  and  runs  off  from,  the  first  sound, 
ending  somewhere  between  the  first  and  the  second,  or  close 
to  the  second  sound.  In  this  case  the  murmur  is  synchro- 
nous with  the  contraction  of  the  ventricles,  and  may  be 
called  ventricular-systolic.  A  ventricular-systolic  murmur, 
being  coincident  with  the  emptying  of  the  ventricles,  must 
of  course  be  caused  (if  valvular  in  origin)  hy  Mood  flowing 
outward  from  the  ventricle,  either  in  the  natural  outward 
direction  (over  a  roughened  aortic  orifice,  for  example),  or 
backward  by  regurgitation  through  the  auriculo-ventricular 
orifices.  When  due  to  obstruction  at  the  arterial  orifices  it 
is  said  to  be  a  direct  murmur,  but  when  caused  by  regurgi- 
tation through  the  auriculo-ventricular  valves,  it  is  named 
indirect  or  backward.  It  may  be  indicated  diagrammati- 
cally,  as  in  Fig.  76.  "  V.S."  is  the  contracted  designation 
for  this  murmur  (Ventricular-Systolic). 

(3)  The  murmur  follows  and  runs  off  from  the  second 
sound,  ending  somewhere  during  the  interval  between  the 
second  sound  and  the  first.  In  this  case  the  murmur  is 
simultaneous  with  the  dilatation  of  the  ventricles,  and  may 
be  called  Ventricular -Diastolic,  and  may  be  represented  as 
in  Fig.  77.  A  "  ventricular-diastolic"  murmur  is  coincident 
with  the  filling  of  the  ventricles  by  their  rapid  expansion- 
movement.  It  is  always  due,  therefore  (if  valvular),  to  blood 
entering  a  ventricle,  either  from  the  auricles  or  from  the  arte- 
rial orifices,  and  in  this  last  case,  of  course,  the  semilunar 


MUEMUBS    WITH    COMPLEX    RHYTHM. 


467 


valves  must  be  deficient  so  as  to  admit  of  the  regurgitation. 
This  is  the  "  Y.D."  (Ventricular-Diastolic)  murmur. 


Fig.  76.     (Cairdner.) 


3 

L                                            J 
2 

1 - 

*       2             '      ■ 

I 

2 

biiiiiiii 

Ve  NTRi 

cuLAR- Diastolic  Mu 

RMUR         (v.  D^ 

»^^^^^ 

rig. 


(Gairdner.) 


VariotfS  combinations  of  these  different  murmurs  occur  not 
unfrequently,  and  this  renders  the  diagnosis  so  much  the 
more  perplexing.  For  instance,  it  is  not  unusual  to  have  an 
"  auricular-systolic  and  a  ven- 
tricular-systolic'^ (A.S.  +  V.S.) 
murmur  combined  (as  in  Fig. 
78),  and  they  may  even  appear 
to  be  so  combined  as  to  constitute 
but  one  murmur.  Commonly, 
however,  the  first  sound  can  be 
detected  in  the  middle  of  this 
murmur,  splitting  it,  as  it  were, 
into  two.  All  that  precedes  the 
sound  is  •'  auricular-S:js,to\\c," 
and  all  that  succeeds  it  is  "  v^h- 
<ricif/a?--systolic."  In  like  man- 
ner, a  '■'■ventricular-systolic'"  and 
a  '•'■  ventricular-diastolic"  (V.S.  +  V.D)  murmur  are  veiy 
frequently  combined  (in  cases  of  aortic  obstruction  and  re- 


Fig.  "S. — Anricular-Sy.stolic 
and  Ventricular-Systolic  mar- 
murs  combiued.     (Gairdner.) 


4G8      PHYSICAL    EXAMINATION    OF    THE    HEART. 

gurgitation),  but  here  the  second  sound  intervenes  and  makes 
the  rhythym  quite  plain  (see  Fig.  79).     The  greatest  degree 


I^^^^^^^PJK^^^VMti^^^^^^^KnKI^^K'mt 


Tig.  7d. — Ventricular-Systolic  and  Ventricalar-Dlastolic  murmurs  combined. 
(Galrdner.) 

of  difficulty  arises  when  the  sound  is  merged  in  the  murmur, 
as  it  often  is,  when  an  ''  auricular-systolic"  and  a  "  ven- 
tricular-systolic" are  combined,  but  even  in  such  a  case  it  is 
often  found  that  the  first  part  of  the  murmur  is  very  rough, 
and  the  second  part  has  often  more  of  a  blowing  character. 


Fig.  80. — Auricular-Systolic,  Ventricular-Systolic  and  Ventricular-Diastolic 
murmurs  combiued.     (Gairduer.) 

The  murmur  will  often,  in  fact,  abruptly  change  its  character 
about  the  moment  of  the  apex-beat,  and  we  may  find  that 
one  element  of  the  complete  murmur  is  heard  more  clearly 
at  the  apex,  and  the  other  at  the  base,  or  elsewhere.  A  very 
complex  association  of  murmurs  is  found  when  all  the  periods 
of  the  heart's  movement  are  accompanied  by  murmur,  ex- 
tending even  through  the  period  of  rest.  This  is  represented 
in  Fig.  80.     (A.S.  +  V.S.  +  V.D.) 


AREAS    OF    CARDIAC    MURMURS.  469 

B.—AREA  OF  CARDIA  C  MURMURS. 

Having  determined  the  rhythm  of  a  murmur,  the  next  step 
in  the  investigation  is  to  fix  within  as  narrow  limits  as  pos- 
sible the  place  of  its  origin. 

The  point  at  which  a  murmur  is  produced  being  in  the 
majority  of  cases  one  of  the  four  valvular  orifices,  it  is  com- 
monly desirable  to  test  all  murmui-s  on  the  supposition  that 
they  are  valvular.  The  first  branch  of  the  inquiry  as  to  the 
seat  of  origin  of  a  murmur  is  therefore  commonly  this  :  at 
which  of  the  four  valvular  orijices  is  it  produced  ?  As  there 
are  four  valvular  orifices,  so  there  are  four  distinctive  areas 
to  which  murmurs  arising  at  these  orifices  maybe  propagated. 
The  following  rules  will  be  found  useful  in  recognizing  these 
areas : 

(1)  Area  of  the  mitral  murrnur.  The  mitral  murmur  cor- 
responds generally  with  the  apex  of  the  left  ventricle.  To 
find  this  area  with  precision  it  is  necessary  to  liave  deter- 
mined all  the  points  about  the  apex-beat  insisted  on  in  the 
earlier  part  of  the  physical  examination.  If  a  murmur  con- 
curs in  position  with  the  apex-beat,  and  if  its  seat  of  diflf'u- 
sion  is  round  this  point  nearly  in  a  circle  (see  Fig.  81,  area 
marked  A.)  ;  or  even,  and  more  especially,  when  the  mur- 
mur is  comn»unicated  more  intensely  and  immediately  to  the 
left  than  to  the  right  of  the  apex,  as  ascertained  by  the  im- 
pulse, it  is  probably  of  mitral  origin.  Mitral  murmurs  are 
often  heard  over  a  very  limited  space  in  front  of  the  thorax  ; 
they  are  mostly  inaudible  at  the  base  of  the  heart :  but,  on 
the  other  hand,  they  are  frequently  conveyed  with  great  dis- 
tinctness to  the  back  of  the  chest,  about  the  lower  angle  of 
the  left  scapula.  They  are  usually  either  "  auricular-systo- 
lic" or  "  ventricular-systolic,"  the  former  being  sometimes 
associated  with  a  "  ventricular-diastolic"  portion,  and  various 
combinations  of  these  occur. 

Naunyn  has  asserted  that  the  murmur  of  mitral  regurgita- 
tion may  have  its  seat  of  intensity,  not  in  the  mitral  area,  as 
above  described,  but  in  the  second  interspace,  one  and  a  half 
or  more  inches  to  the  left  of  the  edge  of  the  sternum,  and 
that  it  is  communicated  to  this  point  from  the  left  auricle 
which  crops  up  on  the  outer  side  of  the  pulmonary  artery. 
He  attributes  this  distribution  of  it  to  the  better  conduction 
of  the  murmur  along  the  course  of  the  regurgitating  blood, 
and  to  the  fact  tliat,  owing  to  its  dilated  condition,  the  left 
auricle  comes  nearer  to  the  surface.  Paul  Niemever, 
40 


470       PHYSICAL    EXAMINATION    OF    THE    HEART. 


Fig.  SI. — Areas  f  (Cardiac  Murmurs  (Gai-dner  for  the  areas:  and  Luscbka 
for  the.  anatomy).  The  outlines  of  organs,  which  are  partially  invisible  in  the 
dissection,  are  indcat'd  by  very  fi'ie  dotted  lines  :  while  the  areas  of  propaga- 
tion of  valvular  iniirmuis,  as  described  in  the  text,  have  been  roughly  marked 
by  additioual  much  coarser  and  more  visible  dotted  lines, — the  character  of  the 
dots  being  different  in  earh  of  the  four  areas.  A  capital  letter  marks  each  area, 
viz..  A,  the  circle  of  uiiral  murmur  corresponding  with  the  left  apex  :  B,  the 
1  regular  space  indicating  the  ordinary  liiniti  of  diffusion  of  aort'c  murmurs, 
corresponding  mainly  with  the  whole  sternum,  and  extending  into  the  nec's. 
along  the  course  of  the  arteries:  C,  the  broad  and  somewhat  diffused  area  oc- 
cupied by  tricup<id  murmurs,  anl  corre-ponding  ge;ierally  with  the  right  ven- 
tricle: D,  the  cir 'um-c  ib  d  ci  cular  area  over  which  pulmunic  uiurraui's  are 
commonly  h'^ard  loudest. 

Rei'ereuce  letters:— r.  au.  =  right  aurcle  ;  a.  o.  =  arch  of  aorta;  v.  i.  =  the 
two  innominate  vein<  ;  v.  c.  =  veui  cava  descen  lens  ;  p.  —  pulmonary  artory ; 
1.  au.  =  left  au:itle  :  1.  v.  —  left  veutiicle  ;  r.  v.  =  right  ventricle. 


AREAS    OF    CARDIAC    MURMURS.  4H 

Gerhardt,  and  George  Balfour  concur  in  this  opinion^  but  the 
question  is  still  suh  judice.  Dr.  George  Balfour  seems  to 
indicate  that  in  ansemic  and  chlorotic  conditions  many  of  the 
so-called  hfemic  murmurs  referred  to  the  area  of  the  pulmonic 
valve  are  in  reality  mitral,  and  their  seat  of  intensity  is  as 
described  above. 

(2)  Area  of  the  pulmonic  murmur.  Murmurs  in  the 
pulmonary  artery,  or  at  the  pulmonic  valves,  are  carried  to 
the  ear  nearly  over  the  seat  of  the  valves,  or  over  the  up]ier 
part  of  the  right  ventricle.  The  circle  D  in  the  diagram 
(Fig.  81)  indicates  the  most  elevated  position  of  the  mur- 
mur, but  it  is  frequently  heard  more  distinctly  a  little  lower 
down.  ]t  coincides  in  position  with  the  greatest  distinctness 
of  the  pulmonic  second  sound  as  contradistinguished  irom 
the  aortic  second  sound.  Frequently  it  coincides  in  position 
with  a  certain  tactile  vibration  or  snap,  as  described  above 
(see  p.  455),  accompanying  the  second  sound.  Pulmonic 
murmurs  are  usually  very  superficial,  and  therefore  often 
very  distinct,  and  apparently  near  the  ear;  they  are  never- 
theless limited  in  their  power  of  diffusion,  being  usually  in- 
audible at  the  apex  and  also  along  the  sternum.  Tliey  are 
never  distinctly  heard  in  the  neck  nor  in  the  course  of  tlie 
great  vessels.  They  are  almost  invariably  ''  ventricular- 
systolic"  in  rhythm,  but  "  ventricular-diastolic"  murmurs 
may  occur,      (Compare  also  last  clause  of  last  paragraph.) 

(3)  Area  of  the  tricuspid  murmur.  This  murmur  is 
heard  over  the  right  ventricle  where  it  is  uncovered  by  tlie 
lung,  i.  e.,  at  the  lower  part  of  the  sternum,  and  over  the 
whole  space  between  this  and  the  seat  of  the  mitral  murmur. 
It  is  usually  very  distinct  and  superficial  in  its  character, 
little  audible,  however,  above  the  third  rib,  and  thus  dis- 
tinguished both  from  the  ])ulmonic,  and  still  more  from  the 
aortic  murmur.  Its  area  in  ordinary  circumstances  is  indi- 
cated by  the  triangular  space  marked  C.  in  Fig.  81,  but  in 
cases  of  considerable  hypertrophy  and  dilatation  of  the  right 
side  of  the  heart,  especially  in  connection  with  emphvsema, 
the  murmur  is  heard  loudest  towards  the  xiplioid  and  along 
the  margin  of  the  sixth  or  seventh  left  costal  cartilage.  The 
rhythm  is  usually  "  ventricular-systolic,"  but  in  rare  in- 
stances it  may  be  "auricular-systolic." 

(4)  Area  of  the  aortic  murmur.  This  murmur  is  found 
not  only  in  great  intensity  over  the  base  of  tl  e  heart  and 
the  manubrium  sterni,  which  are  in  the  immediate  vicinity 
of  the    seat  of  its    production,  but   frequently,  and  not  less 


472      PHYSICAL    EXAMINATION    OF    THE    HEART. 

distinctly,  along  the  whole  line  of  the  sternum ;  rather 
oftener  than  otherwise,  it  is  absolutely  louder  close  to  the 
xiphoid  than  at  many  points  nearer  to  its  origin.  This  is 
specially  true  of  the  diastolic  murmur  (V.  D.).  The  aortic 
murmur  is  distinguished  from  all  the  other  valvular  murmurs 
by  being  propogated  into  the  arteries  of  the  neck.  This  is 
especially  true  of  the  obstructive  murmur,  which  is  usually 
transmitted  with  considerable  intensity ;  the  regurgitant, 
however,  may  be  very  faint  and  almost  inaudible  there. 
The  aortic  murmur  has  often  a  special  distinctness  over  the 
sternal  end  of  the  second  right  costal  cartilage  ("  aortic 
cartilage").  It  is  the  most  widely-diffused  of  all  the  car- 
diac murmurs,  and  can  sometimes  be  traced  to  great  dis- 
tances along  the  spine,  and  even  into  the  extremities.  The 
area  marked  B,  in  Fig.  81,  indicates  the  seat  of  distribution 
of  the  aortic  murmur.  The  murmur  may  be  "ventricular- 
systolic"  or  "  ventricular-diastolic,"  usually  they  are  com- 
bined. 

Pericardial  Murmurs  are  frequently  present  with  both 
sounds  of  the  heart,  and  when  present  with  only  one  it  is 
almost  invariably  the  first.  They  are  to  be  distinguished  in 
part  by  their  special  acoustic  character  of  friction,  grating, 
or  shuffling.  In  general  terms  they  may  be  said  to  be  defi- 
cient in  precision  of  rhythm,  and  especially  in  what  may  be 
termed  accentuation.  They  are  liable  to  change  both  in 
rhythm  and  position  from  time  to  time.  They  are  more 
considerably  altered  as  to  character  and  intensity  by  the 
position  of  the  patient  than  endocardial  murmurs,  and  they 
are  also  more  considerably  and  especially  more  essentially 
altered  in  their  character  by  pressure  with  the  stethoscope. 
Tliey  are  sometimes  heard  along  the  left  margin  of  the  heart 
or  at  the  apex,  but  on  the  whole  they  most  frequently  occur 
over  the  right  ventricle  and  at  the  mid-sternum,  and  are  not 
carried  into  the  arteries  of  the  neck,  or  in  the  direction  of 
the  xiphoid  cartilage. 

Pericardial  murmur  may  be  simulated  by  friction  sound 
in  the  pleura  on  the  borders  of  the  heart.  As  a  rule,  the 
friction  obeys  the  respiratory  rhythm  and  ceases  when  the 
breath  is  held,  but  in  some  instances  the  friction,  though  due 
to  roughening  of  the  pleura,  is  dominated  by  the  cardiac 
movements.  The  distribution  of  the  friction,  the  absence  of 
symptoms  of  cardiac  derangement,  and  perhaps  the  presence 
of  other  signs  of  pleurisy,  may  guide  the  diagnosis. 


CARDIAC    VALVULAR    MURMURS. 


4T3 


TABULAR  VIEW  OF  CARDIAC  VALVULAR  MURMURS. 
A.  Detekmise  the  Rhythm.     B.  Determine  the  Site,  or  Area  of 

DiSTRIBCTIOX. 


Rhythm  of  Mar-     Causes  of  Murmur  having 
mur  I  such  a  Khythm. 


Before  first 
sound  (A.S.). 


After  first 
sound  (V.S.). 


After  second 
sound  (V.D.). 


After  second 
sound  and 
running  up  to 
first  (V.D.-f 
A.S.). 


'  Obstruction  at 
the  (1)  right  or 
(2)  leftauriculo- 
ventricular  ori- 
fice. 

0BSTRUCTION(l)at    f 

thfe  orifice  of  the  | 
aorta,  or  (2)  the  - 
orifice  of  the  pul- 
monary artery. 
Regurgitation  (3) 
through     mitral 
orifice,    or     (4) 
through     tricus- 
pid orifice. 

'  REGrRGITATIOX(l) 

through      aortic 
semilunar  valves 
or    (2)     through  f 
pulmonic     semi-  | 
lunar  valves.        J 

(l)OBSTRUCTIONat    f 

auriculo-ventri 
cular  orifices. 

(2)  Combination  of" 

OBSTRCCTIOX        at 

one  or  other  auri- 
culo  -  ventricular 
orifice  (A.S.  ele- 
ment), and  RE- 
GURGITATION 

through  the  aor- 
tic or  pulmonic 
valves  (V.D.  ele- 
ment). 


Diagnosis  from  Rhythm  and 
Area  combined. 


If  in  mitral  area  s=  obstruc- 
tion OF  MITRAL  orifice. 

If    in  tricuspid  area  =  ob- 
struction   OF    tricuspid 
orifice  (very  rare). 
I  If  in  aortic  area  :=  aortic 
I      obstruction. 
If  in  pulmonic  area  =  pul- 
I      MONic  obstruction  (very 
rare). 

If  in  mitral  area  =b  mitral 

REGURGITATION. 

If  in  tricuspid  area  =  tri- 
cuspid REGURGITATION. 

If  in  aortic  area  =  aortic 

REGURGITATION. 

If  in  pidmonic  area  s=  pul- 
monic        REGURGITATION 
(very  rare). 

If  in  mitral  area  =  mitral 

obstruction. 
If  in   tricuspid  area  =  tri- 

C.SPID  obstruction. 


If  the  two  elements  of  the  mur- 
mur have  separate  areas, 
e.  g.,  viitral  and  aortic, 
this  indicates  mitral  ob- 
struction AND  aortic  re- 
gurgitation. 


Murmurs  due  to  Aneurisms  of  the  Arch  of  the 
Aorta,  especially  of  the  ascending  part,  are  with  difficulty 
distinguished  from  those  of  aortic  valvular  disease.  Some- 
times the  distinction  is  impossible,  or  can  only  be  arrived  at 

40* 


474        PHYSICAL    EXAMINATION    OF    THE    HEART. 

through  the  superadded  signs  of  aneurism.  (See  p.  475.) 
Such  murmurs  are  usually  ventricular-systolic  (V.S.)  in 
rhythm. 

Anjemic  and  Functional  MrRMrns  (so  called  H^- 
Mic),  as  heard  over  the  heart  and  great  vessels,  are  always 
ventricular-systolic  (V.S.)  in  rhythm,  and  they  almost  al- 
ways simulate  aortic  or  pulmonic  murmurs  as  regards  their 
area,  but  in  rarer  instances  mitral.  They  are  to  be  distin- 
guished chiefly  from  murmurs  of  organic  origin  by  the  circum- 
stances in  which  they  occur,  and  by  the  absence  of  symptoms 
of  valvular  disease. 

A  Metallic  Echo  of  one  or  both  Cardiac  Sounds 
may  simulate  a  murmur  and  may  be  produced  by  an  air  filled 
cavity  in  the  neighborhood  of  the  heart  (tubercular  cavity  in 
the  lung,  pneumothorax,  and  the  stomach).  It  is  distin- 
guished by  its  peculiar  hollow,  ringing,  or  booming  quality. 
Reduplication  of  a  sound  is  apt  in  some  cases  to  simulate  a 
murmur,  especially  when  the  reduplication  is  incomplete,  but 
attention  to  details  will  minimize  this  difficulty. 

McRMLRS  in  the  Arteries.  In  almost  all  the  large 
arterial  trunks  a  murmur  ventricular-systolic  (V.S.^)  in 
rhythm  may  be  evoked  by  pressure  with  the  stethoscope. 
Apart  from  this  pressure,  however,  such  a  murmur  is  often 
present  in  the  subclavian  arteries,  more  especially  on  the  left 
side,  and  that  without  any  lesion  at  the  aortic  orifice.  It 
may  be  present  in  anaemic  conditions,  but  is  not  uncommon 
in  apparently  healthy  subjects.  If  however  there  is  a  double 
murmur  (V.S.  and  V.D.)  at  the  aortic  orifice,  the  first  of 
these  is  invariably  carried  into  the  vessels  of  the  neck  with 
considerable  intensity,  and  in  not  a  few  instances  the  second 
is  propagated  in  a  similar  direction  though  much  less  dis- 
tinctly. Duroziez  pointed  out  that  in  certain  diseased  con- 
ditions, especially  in  aortic  insufficiency,  pressure  educed  not 

'  Strictly  speaking,  and  with  reference  to  absolute  accuracy  in- 
deed, the  rhythm  of  an  arterial  murmur  cannot  be  indicated  in 
terms  of  cardiac  derivation  at  all ;  the  exact  time  of  the  arterial 
murmur  produced  by  the  contraction  of  the  ventricles,  and  the  on- 
ward current  in  the  vessels  being  by  so  much  later  than  the  ven- 
tricular systole,  as  the  vessel  is  remote  from  the  heart.  A  more 
strictly  accurate  nomenclature,  therefore,  would  be  to  call  an  arte- 
rial murmur,  such  as  is  here  indicated,  arterial-diastolic,  i.  e.,  coinci- 
dent in  time  with  the  expansion,  diastole,  or  pulse  of  the  individual 
artery  examined.  In  some  cases  the  postponement  of  the  arterial 
murmur  to  the  cardiac  impulse  is  easily  verified,  and  the  above 
term  is  not  only  apposite  and  convenient  but  of  practical  importance. 


THORACIC    ANEURISM.  4Y5 

only  a  systolic  but  also  a  diastolic  murmur  in  the  ^arteries 
chiefly  in  the  femorals,  but  it  has  also  been  found  apart  from 
any  disease  of  tlie  vascular  apparatus. 

Mdrmurs  in  the  Veins  may  also  be  present,  especially 
in  the  large  trunks  at  the  root  of  the  neck.  They  are  hum- 
ming or  musical  in  quality,  and  are  continuous,  and  thus 
easily  differentiated  from  arterial  murmurs  in  the  same  lo- 
cality, which  intermit  with  the  cardiac  action.  This  venous 
hum  (humming-top  sound  or  Bruit  de  Diable)  is  often  asso- 
ciated with  impoverished  states  of  the  blood  (anaemia,  chlo- 
rosis, &c.),  but  does  not  necessarily  indicate  disease.  The 
position  of  the  patient  is  apt  to  influence  both  the  intensity 
and  quality  of  these  murmurs,  the  erect  posture  generally 
rendering  them  louder  and  more  musical :  inspiration  has  a 
similar  effect.     They  are  said  occasionally  to  intermit. 

THORACIC  ANEURISM. 

Incidental  allusions  have  been  made  in  the  preceding  pages 
to  aneurism  of  the  thoracic  aorta  and  its  branches,  but  it 
may  be  well  to  indicate  a  little  more  in  detail  points  to  which 
attention  should  be  given  in  the  investigation  of  this  subject. 
The  position  of  an  aneurism  will  vary  according  to  the  por- 
tion of  the  vessel  involved.  It  may  impinge  on  the  thoracic 
wall  in  the  immediate  neighborhood  of  the  heart  or  at  almost 
any  point  in  the  upper  part  of  the  thorax,  and  aneurisms  of 
the  innominate  branch  of  the  aorta  may  even  reach  high  up 
into  the  neck.  A  very  frequent  seat  of  thoracic  aneurism  is 
under  the  manubrium  sterni.  Aneurisms  of  the  ascending 
arch  are  said  to  pass  chiefly  to  the  right  of  the  sternum,  those 
of  the  transverse  arch,  lie  as  a  rule  under  the  manubrium, 
while  those  of  the  descending  arch  tend  to  the  left  side.  No 
fixed  rules  can  be  lai  1  down  however ;  in  some  instances  the 
pressure  signs  and  symptoms  may  aid  us  in  determining  the 
portion  involved. 

,  Aneurism  in  the  thorax  often  causes  a  local  bulging  of  the 
chest  wall,  and  when  looked  at  in  a  cross  light  this  bulging 
may  be  seen  to  pulsate,  while  palpation  at  once  detects  the 
heaving  action.  If  the  aneurism  has  by  its  pressure  eroded 
any  portion  of  the  bony  structure  it  may  present  itself  as  a 
disliiict  pulsating  tumor,  the  impulse  being  separable  from 
that  of  the  heart  both  by  position  and  rhythm  (the  cardiac 
impulse  preceding  that  of  the  aneurism  by  an  instant),  and 
if  the  tumor  is  grasped  by  its  periphery  between  the  fingers, 


476      PHYSICAL    EXAMINATION    OF    THE    HEART. 

Xhe,  pulsation  is  found  to  he  erpan^ile  or  eccentric,  and  this 
is  a  very  valuable  diagnostic  point  from  glandular  tumors, 
cancerous  growths,  abscesses,  &c.,  in  the  mediastinum,  which 
mav  simulate  aneurism  by  having  the  heave  of  the  aorta 
communicated  to  them.  In  rare  instances  the  aneurism  may 
yield  a  double  impulse,  a  systolic  and  a  diastolic  ;  the  latter, 
or  "  impulse  of  arrest,"  as  it  is  sometimes  called,  being  gen- 
erally slight  when  present  at  all.  A  distinct  thrill  is  also 
occasionally  felt,  most  frequently  in  aneurisms  near  the 
heart.  Along  with  these  signs  there  will  be  an  area  of  dull 
percussion^  which,  according  to  the  size  and  position  of  the 
aneurism,  mav  be  separable  from  the  cardiac  dulness,  joined 
to  it  bv  a  more  or  less  narrow  neck,  or  quite  continuous 
"with  it. 

In  many  instances,  however,  no  distinct  pulsating  tumor 
is  present,  although  there  may  be  an  obscure  heave,  and  the 
only  definite  physical  signs  are  an  area- of  percussion-dul- 
ness,  more  or  less  marked,  in  the  track  of  the  aorta,  and 
certain  auscultatory  phenomena  to  be  mentioned  immedi- 
ately. Sometimes,  indeed,  even  these  signs  are  wanting  or 
very  obscure,  and  the  diagnosis  may  rest  almost  entirely  on 
other  signs  and  symptoms,  such  as  fixed  pain,  dyspnoea, 
hsemoptssis,  signs  of  pressure  on  nerves  and  veins,  displace- 
ments of  the  trachea,  backwards  or  to  either  side,  sense  of 
fulness  in  the  jugular  fossa,  changes  in  the  pupils,  pulses, 
&c.  (see  Cliapter  ix.). 

The  auscultatory  signs  may  vary.  In  some  instances, 
especiallv  where  the  tumor  involves  the  first  part  of  the 
ascending  arch,  murmurs  following  both  sounds  (V.S.  and 
V.D.)  mav  be  present,  owing  to  implicalion  of  the  aortic 
valves.  But  independent  of  any  such  condition,  murmurs 
may  be  found  in  aneurisms  in  any  part  of  the  thorax,  the 
rhythm  being  usually  "  ventricular-systolic,"  or,  more  cor- 
rectly, arterial-diastolic,  as  it  corresponds  with  the  expansion 
of  the  artery.  In  many  instances,  however,  no  murmur  is 
present,  but  the  cardiac  sounds  may  have  undergone  altera- 
tion, as  heard  over  the  suspected  area.  Both  sounds  may 
have  become  very  distinct,  sometimes  even  more  so  than 
over  the  cardiac  region  ;  the  second  is  especially  apt  to  be 
accentuated,  and  even  develops  a  different  quality,  Vjecoming 
deepened  in  tone  or  ••  booming,"  and  this  cliaracter  is  trans- 
mitted into  the  vessels  of  the  neck.  This  mere  change  in 
the  second  sound  would  not  warrant  any  diagnosis  of  aneur- 
ism, us  there   are   otl..-;-  conditions  which  induce  it   (see  p. 


THORACIC    ANEURISM.  ill 

463).  In  aneurismal  conditions  it  is  sometimes  wanting, 
but  when  present  with  symptoms  such  as  are  indicated 
above  and  accompanied  by  an  area  of  dull  percussion  in  the 
line  of  the  aorta,  the  presumption  of  aneurism  becomes  very 
strong. 

Simple  dilatation  of  the  arch  of  the  aorta  may  give  rise  to 
varying  degrees  of  percussion-dulness,  chiefly  in  the  region 
of  the  manubrium  sterni.  There  is,  as  a  rule,  no  visible  or 
tangible  impulse  over  this  area ;  but  if  the  finger  is  inserted 
into  the  jugular  fossa,  the  dilated  vessel  may  be  easily  felt, 
and  its  impulse  recognized.  The  second  sound  is  usually 
accentuated  and  booming,  but  pressure  symptoms  are  as  a 
rule  absent. 

Signs  of  aneurism  may  present  themselves  in  the  back  of 
the  thorax.  Percussion-dulness  of  limited  area,  and  close 
to  the  left  side  of  the  spine,  with  changes  in  the  cardiac 
sounds  and  symptoms  of  pressure,  as  already  indicated,  have 
to  be  chiefly  relied  on.  Indeed,  in  many  such  cases  physical 
examination  may  yield  little  information,  and  the  diagnosis 
may  depend  chiefly  on  the  symptoms. 

The  conditions  most  likely  to  simulate  aneurism  are  visi- 
ble and  tangible  pulsation  from  the  pulmonary  artery  or  left 
auricle,  about  the  second  left  intercostal  space  (for  diagnosis 
see  p.  455),  pulsating  empyema,  and  cancerous  tumors. 
Pulsating  empyema  usually  occupies  the  normal  situation  of 
the  heart,  which  is  found  displaced  to  the  right,  and  commu- 
nicates its  impulse  to  the  fluid  coUecticm.  There  is  as  a  rule 
a  distinct  history  of  a  pleuritic  attack,  and  it  is  unattended 
by  murmur,  thrill,  or  alteration  in  the  cardiac  sounds.  Pul- 
sating cancer  ma,y  present  more  difficulty,  as  it  may  be 
attended  by  murmur,  and  give  rise  to  all  the  pressure  symp- 
toms already  indicated.  But  careful  palpation  may  detect 
that  the  pulsation  is  not  so  distinctly  expansile  as  in  aneu- 
rism, nor  does  the  centre  of  pulsation  correspond  to  that  of 
dulness.  The  glands  in  the  neighborhood  that  are  accessible 
may  be  discovered  enlarged,  the  cachexia  may  be  well 
marked,  and  the  sounds  of  the  heart  over  the  dull  area, 
except  in  so  far  as  attended  by  murmur,  do  not  present  the 
alterations  so  often  found  in  aneurismal  conditions. 


4TS      PHYSICAL    EXAMINATION    OF    THE    ABDOMEN. 


PART  III.— PHYSICAL  EXAMINATION  OF  THE  ABDOMEN. 

Anatomists  have  divided  the  abdomen  into  various  regions 
by  lines  drawn  from  certain  fixed  points,  viz.,  two  horizontal 
lir.es  passing  across  the  body,  the  one  at  the  lowest  points  ot* 
the  costal  arch,  and  the  other  at  the  highest  part  of  the  iliac 
crests :  two  vertical  lines  are  drawn  down  perpendicularly 
from  the  cartilage  of  the  eighth  rib  to  the  middle  of  Pou- 
])art's  ligament  on  either  side.  Tlie  central  regions  are  tlie 
Epigastric,  the  Umbilical,  and  the  Hypogastric,  and  on  either 

side  of  these  the  Right  and 
Left  Hypochondriac,  Lum- 
bar, and  Iliac.  (See  Fig. 
82.)  Some  clinical  ob- 
servers have  devised  other 
lines  for  these  divisions, 
but  the  difference  in  the 
regions  is  only  slight.  (See 
the  dotted  lines  in  Bright's 
Diagram,  Fig.  41 ,  p.  341.) 
It  is  well  to  have  a 
general  notion  of  what  or- 
gans occupy  these  regions. 
In  the  right  hypochon- 
drium  lies  the  right  lobe 
of  the  liver  ;  in  the  epigas- 
tric region  the  body  of  the 
stomach,  the  left  lobe  of 
the  liver,  and  behind  the 
stomach  the  pancreas;  in 
the  left  hypochondrinm  the  cardiac  extremity  of  the  stomach 
and  the  spleen  ;  in  the  umhilical  region  the  transverse  colon, 
the  mesentery,  and  part  of  the  small  intestine ;  in  the  right 
lumbar  region  the  right  kidney  and  the  ascending  colon;  in 
the  left  lumbar  region  the  left  kidney  and  descending  colon ; 
in  the  hypogastrium  the  small  intestine  and  the  bladder 
when  distended  ;  in  iheleft  iliac  region  tiie  sigmoid  flexure; 
and  in  the  right  iliac  region  the  "  caput  caecum  coli."  (See 
Fig.  83.) 

The  methods  employed  in  the  physical  examination  are 
similar  to  those  already  indicated  in  the  case  of  the  chest — 
viz.,  inspection,  palpation,  percussion,  mensuration,  and 
auscultation.     The  last  of  these  is  of  very  limited  scope  in 


Fig   82. — The  Anatomical  regions 
of  the  abdomeu. 


ABDOMINAL    VISCERA    IN    SITU. 


4T9 


the  abdomen  compared  with  the  chest,  but  all  of  them  should 
be  used  so  as  to  check  each  other  at  every  step  of  the  inquiry. 
Before  commencing  the  examination  the  pat  ent  should, 
as  a  rule,  be  laid  on  his  back,  with  the  shoulders  a  little 
raised,  and  the  thighs  slightly  flexed  on  the  pelvis  to  relax 
the  abdominal  muscles.  He  should  be  directed  also  to  ke  'p 
Lis  mouth  open,  and  breathe  quietly. 


Fig.  S3. — Abdom.intil  viscera  in  situ.  Tbe  omentum  has  been  removed :  the 
costal  arch  has  beea  preserved.  The  capital  letters  are  the  initials  of  the 
structures  on  which  they  are  placed:  L,  lungs;  D,  diaphragm;  E,  ribs  ;  S, 
spleen;  B,  bladder.    (From  Marshall's  Physiological  Diagrams.) 


INSPECTION. 

The  abdomen  being  well  exposed,  inspection  will  deter- 
mine its  shape,  the  condition  or  the  superficial  parts,  the 
respiratory  movements,  and  any  other  movements  or  pulsa- 
tions which  may  exist. 

In  healthy  women  and  children  the  abdomen  protrudes 
more  than  in  adult  males,  in  whom,  in  the  recumbent  pos- 
ture, it  is  often  somewhat  flattened.  If  the  subject  is  fat, 
the  surface  will  be  free  from  marked  inequality ;  but  if  the 


480      PHYSICAL    EXAMINATION    OF    THE    ABDOMEN. 

parietes  contain  little  fat,  and  the  recti  muscles  are  Avell  de- 
veloped, they  may  stand  out  somewhat  on  either  side  of  the 
middle  line.  The  abdomen  may  become  much  distended 
from  accumulation  of  gas  in  the  intestines  (see  Tympanites, 
p,  496),  or  from  fluid  effusion  into  the  peritoneum  (see  As- 
cites, p.  497),  or  from  ovarian  tumors,  «&:c.  (see  p.  499),  or 
combinations  of  these;  or  the  bulging  may  be  local  from 
tumor  of  some  of  the  solid  organs,  or  from  undue  distension 
of  some  of  the  hollow  viscera,  such  as  the  stomach  in  stric- 
ture of  the  pylorus.  On  the  other  hand  it  may  become 
much  retracted  in  certain  cerebral  affections  (tubercular 
meningitis),  in  chronic  lead  poisoning,  and  in  cases  of  ob- 
struction high  up  in  the  alimentary  canal  leading  to  inani- 
tion. The  umbilicus  occu])ies  a  point  about  midway,  as  a 
rule,  between  the  pubes  and  the  xiphoid,  but  is  subject  to  a 
certain  degree  of  variation,  and  in  very  young  children  is 
nearer  the  pubes.  In  the  strictly  normal  condition  it  is  de- 
pressed, but  it  may  bulge  as  in  umbilical  protrusion,  and  in 
cases  of  ascites.  During  the  later  months  of  pregnancy, 
also,  it  becomes  prominent.  The  skin  is  normally  somewhat 
darker  round  the  umbilicus  than  on  the  other  parts  of  the 
abdomen,  forming  what  is  called  the  "areola,"  and  this  pig- 
mentation becomes  more  marked  during  the  course  of  preg- 
nancy; and  in  Addison's  disease  it  is  a  marked  feature — 
the  whole  surface,  however,  being  unduly  pigmented.  In 
women  "a  brown  line"  is  sometimes  seen  extending  from 
the  umbilicus  to  the  pubes,  and  is  by  some  reckoned  a  sign 
of  pregnancy ;  but  this  is  to  be  accepted  with  reservation. 
It  is  sometimes  also  found  in  males.  In  women  who  have 
born  children  the  abdominal  walls  are  often  very  flaccid,  and 
in  some  cases,  after  many  pregnancies,  become  so  thin  as  to 
give  the  impression  that  there  is  little  else  than  a  layer  of 
skin  covering  the  intestines.  White  lines,  "water  lines" 
(lineae  albicantes),  occur  on  the  skin  after  the  distension  of 
pregnan(;y,  and  after  the  absorption  of  large  dropsical  effu- 
sions. Occasionally  the  superficial  veins  are  much  enlarged 
and  tortuous,  this  condition  being  generally  associated  with 
some  obstruction  to  the  portal  circulation,  as  in  cirrhosis,  or 
with  some  pressure  on  the  inferior  vena  cava  by  tumors. 
The  abdominal  parietes  may  be  dropsical,  and  pit  on  pres- 
sure. This  oedema  is  always  greatest  in  the  dependent 
parts,  often  accompanied  by  fluid  effusion  into  the  cavity  of 
the  peritoneum,  and  usually  associated  with  dropsical  effu- 
sio.i  into  the  cellular  tissue  of  other  parts  of  the  body.     The 


ABDOMINAL    MOVEMENTS    AND    PULSATION.      481 

abdomen  is  frequently  the  seat  of  skin  eruptions ;  some  of 
the  febrile  rashes  indeed,  as  enteric,  have  a  tendency  to  ap- 
pear there  first.  All  such  rashes,  of  course,  should  be  noted 
and  described  if  present. 

The  degree  to  which  the  abdominal  walls  participate  in 
the  respiratory  act  is  to  be  carefully  observed.  In  quiet  res- 
piration in  males  the  abdominal  movement  is  more  marked 
than  the  thoracic ;  while  in  females  the  thoracic  movement 
predominates.  The  type  in  the  male  is  thus  said  to  be  "  ab- 
dominal," and  in  the  female  "  thoracic."  This  abdominal 
movement  may  be  much  restricted  in  various  conditions. 
Anything  which  causes  distension  of  the  abdomen,  and 
hinders  the  descent  of  the  diaphragm,  will  necessarily  do  so, 
and  all  forms  of  abdominal  intumescence  may  in  this  way  be 
causes  of  it.  In  women  the  respiration  is  made  more  thoracic 
by  the  presence  of  such  conditions,  and  pregnancy  has  neces- 
sarily the  same  result.  But  apart  from  such  cases,  it  may  be 
greatly  restricted  from  voluntary  eifort,  owing  to  the  pain 
which  it  excites,  as  in  peritonitis,  diaphragmatic  pleurisy,  or 
pericarditis.  But  this  abdominal  respiratory  movement  may 
be  exaggerated  when  from  any  cause  the  thoracic  movements 
are  restricted,  and  the  chief  work  of  the  respiratory  process 
is  thrown  upon  the  diaphragm.  This  is  the  case  in  large 
pleural  elFusions,  in  extensive  consolidations  of  the  lung,  and 
in  emphysematous  and  asthmatic  conditions. 

A  degree  of  pulsation  is  occasionally  visible  in  the  epigas- 
tric region,  and  may  be  due  to  the  heave  communicated  from 
the  aorta.  It  is  most  frequently  seen  in  females,  especially 
those  who  are  thin  and  of  nervous  temperament :  it  must  not 
be  confounded  with  the  epigastric  pulsation  communicated 
from  the  heart  (see  page  455).  But  visible  pulsation  may 
exist  in  the  abdomen  from  aneurism  of  the  aorta  or  any  of 
its  branches ;  and  cancerous  or  other  tumors  may  simulate 
pulsations  from  their  lying  over,  the  vessel  and  having  its  im- 
pulse communicated  to  them.  All  the  methods  of  inquiry 
must  be  brought  to  bear  in  the  investigation  of  such  cases. 
In  subjects  in  whom  the  stomach  or  intestines  are  much  in- 
flated owing  to  any  obstruction,  peristaltic  action  may  occa- 
sionally be  seen  through  the  abdominal  walls  ;  this  may  also 
be  visible  in  the  extremely  thinned  condition  of  the  integu- 
ments already  referred  to. 

41 


482       PHYSICAL    EXAMINATION    OF    THE    ABDOMEN. 

PALPATION 

is  a  method  of  investigation  ^videly  applicable  in  abdominal 
diagnosis,  and  should  be  followed  out  with  much  detail.  The 
hands  of  the  examiner  should  not  be  cold,  as  this  is  apt  to 
cause  the  patient  to  shrink  :  and  the  palpation  should  not  be 
conducted,  at  least  in  the  first  instance,  in  a  jerky  or  spas- 
modic manner  with  the  tips  of  one  or  two  fingers,  but  with 
the  whole  palmar  surface  of  them  applied  gently  but  firmly. 
As  the  results  of  this  method  of  examination  will  be  given 
in  detail  under  the  various  organs,  only  a  few  general  facts 
need  be  noted  here.  It  will  determine  the  state  of  the  tem- 
perature of  the  surface,  the  presence  of  flaccidity  or  rigidity 
of  the  walls,  the  condition  of  the  abdominal  rings,  the  de- 
gree of  resistance  at  different  points,  and  whether  parts  are 
freely  movable ;  when  associated  with  percussion  it  enables 
us  to  detect  fluid  in  the  peritoneum  (see  Ascites,  p.  497).  It 
will  reveal  the  fact  of  smoothness  or  irregularity  of  the  ab- 
dominal organs  ;  it  will  determine  the  presence  and  charac- 
ter of  pulsations  ;  and  peritoneal  friction  may  sometimes  even 
be  detected  by  it.  This  is  got  either  by  causing  the  patient 
to  breathe  forcibly  while  the  flat  of  the  hand  is  laid  over  the 
suspected  organ,  or  it  maybe  elicited  by  sliding  the  abdomi- 
nal wall  over  the  part  (see  p.  342).  In  the  case  of  abdomi- 
nal tumors  palpation  will  determine  their  characters,  and 
whether  they  are  affected  by  respiration  or  not ;  tumors 
closely  associated  with  the  movable  organs  lying  beneath  the 
diaphragm  being  depressed  and  elevated  in  respiration.  Pal- 
pation may  also  determine  the  fact  of  pregnancy  by  noting 
the  movements  of  the  fcetus  in  the  uterus,  as  well  as  ena- 
bling us  in  certain  cases  where  the  abdominal  Avails  are  thin, 
or  in  an  extra-uterine  foetation,  to  recognize  the  head,  feet,  or 
other  parts  of  the  child.  It  also  elicits  important  information 
as  to  the  presence  or  absence-of  pain  or  tenderness.  In  cer- 
tain conditions  pain  is  so  acute  as  to  forbid  palpation.  This 
is  especially  (but  not  invariably)  the  case  in  acute  peritonitis, 
where  the  pain  is  often  so  exquisite  as  to  lead  the  patient  to 
flex  the  thighs  upon  the  pelvis  in  order  to  relax  the  abdomi- 
nal muscles  and  protect  the  belly  from  the  pressure  of  the 
bed-clothes.  On  the  other  hand,  acute  pain  when  of  the 
neuralgic  or  colicky  type  is  sometimes  relieved  by  pressure. 
If  tenderness  on  pressure  exists  over  a  limited  area  in  the 
epigastric  region,  it  may  point  to  the  presence  of  gastric 
ulcer ;  and  in  inflamed  or  suppurating   conditions  of  any  of 


PERCUSSION — MENSURATION — AUSCULTATION.      483 

the  organs  or  structures  in  the  fibdomen,  pain  on  pressure  is 
as  a  rule  a  marked  feature. 

PERCUSSION 

is  to  be  performed  in  the  manner  described  in  the  section  on 
the  physical  diagnosis  of  the  lungs.  The  note  yielded  over 
the  air-filled  organs  in  the  abdomen  is  tympanitic,  having  a 
distinct  musical  tone,  and  the  quality  of  this  note  varies 
according  to  the  size  and  degree  of  distension  of  the  organs. 
The  note  obtained  over  the  stomach  is  fuller  and  lower  in 
pitch  than  that  over  the  colon  ;  the  note  over  the  colon  bears 
a  similar  relation  to  that  over  the  small  intestine.  It  is  by 
means  of  this  change  in  quality  that  the  different  parts  of 
the  intestine  can  be  distinguished  from  each  other,  and  the 
student  should  study  them  in  this  light,  contrasting  the  per- 
cussion tone  with  that  obtained  over  a  solid  organ  such  as 
the  liver,  which  is  "  dull,"  and  that  obtained  over  the  lung 
which  is  termed  "clear."  Auscultatory  percussion  is  some- 
times of  value  in  the  delimitation  of  air-filled  organs  (see 
below). 

MENSURATION 

is  used  to  determine  the  circumference  of  the  abdomen,  the 
tape  being  applied  at  the  most  prominent  part,  usually  a 
little  above  or  below  the  umbilicus,  or  at  some  other  definite 
point.  This  gives  a  datum  for  future  measurements,  and 
increase  or  decrease  can  readily  be  determined,  care  being 
taken  that  the  tape  is  applied  at  the  same  level  and  with  the 
same  tension.  The  distance  of  the  umbilicus  from  the  ensi- 
form  cartilage  or  the  pubes  has  occasionally  to  be  noted. 
The  areas  of  percussion-dulness  of  the  various  organs, 
whether  normal  or  abnormal,  should  be  accurately  measured 
and  stated,  and  points  to  be  indicated  should  be  measured 
from  definite  anatomical  landmarks  such  as  the  umbilicus, 
ensiform  cartilage,  iliac  spines,  &c.,  and  not  vaguely  referred 
to  the  regions  in  which  they  lie. 

AUSCULTATION 

is  of  chief  value  in  abdominal  diagnosis  in  the  detection  of 
vascular  sounds,  whether  connected  with  abnormal  conditions 
such  as  aneurism,  uterine  tumors,  &c.  (see  p.  500),  or  with 
normal  conditions  during  pregnancy  (for  foetal  heart,  uterine 


484      PHYSICAL    EXAMINATION    OF    THE    ABDOMEN. 

souffle,  &c.,  see  p.  414).  It  is  also  applicable  in  dilatation 
of  the  stomach  to  determine  the  fact  of  succussion  (see  p. 
495),  and  occasionally  in  the  determination  of  peritoneal 
friction,  chiefly  over  the  liver.  It  may  be  used  in  the  diag- 
nosis of  stone  in  the  bladder,  the  stethoscope  being  placed 
above  the  pubes,  while  the  stone  is  struck  with  the  sound. 
"Auscultatory  percussion"  is  sometimes  used  to  delimit  air- 
filled  organs,  such  as  the  stomach.  For  this  purpose  the 
observer  places  his  stethoscope  over  the  epigastrium  while  an 
assistant  percusses  from  the  periphery,  till  a  point  is  reached 
at  which  the  note  is  communicated  with  sudden  and  great 
directness  to  the  listener,  and  tliis  may  be  marked  as  the 
confine  of  the  organ.  The  same  method  is  pursued  all  round 
the  stomach,  the  patient's  position  being  altered  to  allow  the 
fluid  to  change  its  place,  and  the  area  occupied  by  the  viscus 
can  thus  be  mapped  out  with  tolerable  exactitude,  if  the 
note  of  the  colon  does  not  approximate  to  that  of  the  stomach. 
It  is  absolutely  necessary  to  shift  the  patient  from  one  side 
to  the  other  in  this  examination,  otherwise  only  the  level  of 
the  fluid  contained  in  the  stomach"  will  be  ascertained. 

The  most  convenient  method,  probably,  of  treating  of 
abdominal  diagnosis  is  to  take  up  the  principal  organs  in 
detail,  considering  them  first  in  their  normal  relations,  and 
then  passing  on  to  abnormal  conditions.  In  such  an  ar- 
rangement the  liver  naturally  claims  attention  first. 

LIVER. 

In  the  section  devoted  to  the  physical  examination  of  the 
lungs  it  was  noticed  that  the  pulmonary  percussion  was 
bounded  inferiorly  all  round  the  right  side  by  the  upper 
margin  of  hepatic  dulness.  In  order  to  define  this  margin, 
the  percussion  should  be  carried  from  the  clear  pulmonary 
area  down  on  to  the  dull  liver,  using  a  light  stroke,  and  at  a 
point  one  inch  and  a  half  or  two  inches  below  the  right  nip- 
ple, a  change  will  be  perceived  in  the  note,  as  well  as  in  the 
sense  of  resistance,  and  this  indicates  the  spot  at  which  the 
lung  ceases  to  overlap  the  liver.  This  is  the  boundary  of 
"  absolute"  dulness  ;  the  deep  or  "  relative"  dulness  which 
indicates  the  highest  point  to  which  the  liver  ascends  under 
the  diaphragm  is  at  a  considerably  higher  level  than  this, 
and  is  got  with  strong  percussion  performed  during  expira- 
tion.    The  description  here  given  will  apply  to  the  superfi- 


LIVER.  485 

cial,  or  absolute  dulness.  The  upper  border  is  followed  into 
the  cardiac  dulness  in  almost  a  straight  line — there  being, 
however,  a  tendency  for  it  to  descend  a  little  towards  the 
inner  extremity,  where  it  joins  the  precordial  dulness  on  a 
level  with  the  base  of  the  ensiform  cartilage.  It  is  then 
extended  in  the  lateral  region  and  the  back,  and  will  be 
found  to  descend  somewhat  as  it  nears  the  spine,  usually  at 
the  tenth  or  eleventh  dorsal  vertebra.  Having  marked  this 
upper  limit  of  percussion  with  ink  or  otherwise,  the  lower 
margin  will-  next  engage  attention,  the  percussing  stroke 
being  carried  up  from  the  tympanitic  intestine.  Tliis  lower 
margin  in  the  right  mammary  line  will  be  found  to  coincide 
pretty  exactly  with  tbe  margin  of  the  ribs ;  in  the  axillary 
line  it  corresponds  to  about  the  tenth  intercostal  space,  and 
it  crosses  the  epigastrium  at  a  level  of  about  two  inches 
below  the  xiphoid,  and  joins  the  left  margin  of  the  cardiac 
dulness.  The  left  lobe  of  the  organ  can  thus  be  felt  in  the 
epigastrium,  giving  a  sense  of  increased  resistance ;  but,  as  a 
rule,  its  lower  edge  cannot  be  strictly  defined  by  palpation. 

The  average  extent  of  hepatic  dulness,  according  to  this 
mode  of  percussion,  in  a  healthy  adult  of  medium  size  is 
from  2-5-  to  3  inches  in  the  mesial  line  of  sternum,  4  inches 
in  the  line  of  the  nipple,  and  4:\  or  5  inches  in  the  axillary 
line. 

It  must  be  remembered  that  these  limits,  which  pi-esup- 
pose  the  recumbent  posture,  may  alter  to  some  extent  on  the 
patient's  assuming  the  erect  attitude,  and  in  certain  condi- 
tions of  respiration.  Thus,  on  deep  inspiration,  the  whole 
organ  is  somewhat  depressed,  and  its  upper  limit  overlapped 
to  a  greater  extent  by  the  lung.  The  student  should  be 
careful  to  appreciate  these  changes.  In  children  in  whom 
the  liver  is  naturally  large,  the  upper  margin  of  dulness  may 
approximate  to  the  nipple,  and  the  lower  descend  somewhat 
beneath  the  costal  arch ;  and  there  are  various  deformities 
of  the  chest,  such  as  those  induced  by  rickets,  emphysema, 
and  tight  lacing,  which  tend  to  throw  the  organ  to  a  greater 
or  less  extent  from  under  the  cover  of  the  ribs,  and  so  simu- 
late enlargement.  Congenital  malformations  of  the  organ 
may  also  be  present. 

The  demarcation  of  the  lower  edge  of  the  liver  should 
never  be  considered  as  settled  from  a  single  examination,  as 
there  are  various  conditions  which  temporarily  affect  it. 
Thus,  if  the  stomach  and  intestines  are  distended  with  gas, 
they  may  conceal  the  lower  edge,  and  the  area  of  dulness 

41* 


486      PHYSICAL    EXAMINATION    OF    THE    ABDOMEN. 

may  appear  diminished.  Again,  if  the  examination  is  made 
after  a  full  meal,  the  dull  percussion  from  the  stomach  may 
mask  the  lower  edge  of  hepatic  dulness  ;  or  there  may  be 
accumulation  of  feces  in  the  colon  having  a  similar  effect. 
In  cases  of  thickened  omentum  also,  where  the  recti  mus- 
cles are  vei-y  rigid,  or  where  there  is  dropsy  of  the  abdominal 
wall  or  of  the  peritoneum,  the  exact  determination  of  the 
lower  edge  may  be  very  difficult  or  even  impossible. 


Fig.  84. — Displacement  of  cardiac  and  hepatic  d'tlnevs  in  emphysema  of 
the  luugs.     (Weil.) 

Large  abdominal  tumors,  by  their  pressure  upAvards,  will 
tend  to  push  the  liver  further  under  the  ribs,  and  so  raise 
both  its  upper  and  lower  limits  of  percussion  ;  while  pleural 


ENLARGEMENT    OF    THE    LIVER.  487 

effusions  of  air  or  fluid,  marked  emphysema  of  the  lungs, 
tumors  in  the  chest,  and  enlargements  of  the  heart  will  de- 
press the  organ  into  the  abdomen.  The  diagnosis  in  such 
cases  must  be  guided  by  the  history  and  other  physical  signs. 

The  size  of  the  liver  is  liable  to  vary  to  some  extent  even 
in  health  under  the  influence  of  diet ;  but  this  is  only  a 
temporary  fact.  In  all  cases  where  the  liver  is  permanently 
increased  in  bulk,  the  enlargement  is,  as  a  rule,  chiefly  in 
the  downward  direction — the  liver  projecting  beyond  the 
ribs,  and  palpation  becoming  a  valuable  means  of  diagnosis. 

The  student  must  be  careful  to  distinjiuish  enlaro^ement 
from  displacement  of  the  organ.  The  distinction  in  cases 
of  emi)hysema,  tight-lacing,  or  rickety  or  other  deformities  of 
the  chest,  lies  in  the  fact  that  in  the  displacement  the  upper 
level  of  hepatic  dulness  will  be  found  to  be  lowered  to  a 
greater  or  less  extent  according  to  the  degree  of  projection 
from  under  the  ribs  (see  Fig.  84) ;  whereas,  in  enlargement, 
the  upper  limit  of  dulness  maintains  its  position,  and  in  some 
instances  is  even  on  a  higher  level,  approximating  to  the 
nipple.  Wlien,  however,  the  displacement  is  due  to  right 
pleural  eflFusion,  the  distinction  may  be  less  easily  drawn,  as 
tlie  upper  border  of  liver  dulness  is  merged  in  tliat  of  the 
effusion  ;  but  the  history,  symptoms,  and  other  physical 
signs  will  usually  give  the  key  to  the  condition.  In  pericar- 
dial effusion,  hypertrophy  of  the  heart,  and  left  pleural  effu- 
sion, the  left  lobe  is  the  part  chiefly  depressed,  and,  as  the 
upper  limit  of  the  right  is  not  much  affected,  there  is  not  the 
same  liability  to  fallacy  as  in  pleural  effusion  on  the  right 
side.     (Compare  Figs.  72  and  73,  pp.  459  and  460.) 

The  enlargement  of  the  liver  may  affect  the  xohole  organ 
uniformly^  or  it  tnay  he  localized^  and  it  may  be  moderate 
in  extent,  or  fill  the  whole  abdomen.  When  the  liver  is 
uniformly  enlarged,  the  outline  of  the  organ  is  not  materially 
altered.  The  percussion  of  its  limits  should  be  followed  out, 
and  palpation  should  always  be  brought  to  test  the  lower 
margin  ;  in  not  a  few  instances  it  will  be  found  that  the 
lower  edge  can  be  felt  to  project  to  a  quite  decided  extent 
beyond  the  limit  of  percussion-dulness.  This  is  especially 
the  case  in  fluid  effusion,  and,  to  detect  the  lower  edge  in 
such  instances,  it  is  frequently  necessary  to  pursue  palpation 
in  a  different  method  from  that  indicated  in  the  commence- 
ment of  this  section.  It  has  to  be  done  with  the  tips  of  the 
fingers,  suddenly  and  strongly,  in  order  to  penetrate  to  the 


488      PHYSICAL    EXAMINATION    OF    THE    ABDOMEN. 

liver.  It  is  often  possible  also  in  uniform  enlargement,  to 
map  out  the  notch  of  the  liver,  which  will  be  found  some- 
what near  the  mesial  line  of  the  abdomen,  and  it  may  be 
appreciable  not  only  by  palpation,  but  as  a  small  bay  of  clear 
percussion  penetrating  the  line  of  dulness.  In  some  in- 
stances, also,  where  the  fissure  of  the  gall-bladder  is  well 
marked,  it  can  be  detected,  though  with  nothing  like  the 
frequency  of  the  notch.  In  ascites  the  percussion  of  the 
lower  edge  of  the  liver  cannot  be  depended  on,  and  palpation 
has  to  be  chiefly  used  in  the  delimitation  of  it.  In  uniform 
enlargement  the  upper  limit  of  dull  percussion  approaches 
the  nipple  level ;  and  when  the  increase  in  size  is  considera- 
ble, it  is  often  possible,  by  applying  the  one  hand  in  front 
and  the  other  in  the  lumbar  region  behind,  to  grasp  the 
organ  and  communicate  a  sense  of  impact  from  the  one  hand 
to  the  other. 

Density,  Smoothness,  and  Irregularity. — The  hepatic  re- 
gion in  cases  of  enlargement  can  often  be  seen  distinctly 
bulged,  and,  on  applying  the  hand  over  the  part  that  pro- 
jects, the  senseof  resistance  and  the  fact  of  smoothness  or 
irregularity  of  the  surface  will  be  recognized.  If  the  organ 
is  smooth,  uniformly  enlarged,  dense  and  resistant,  it  is  most 
probably  either  amyloid,  fatty,  congested,  or  the  seat  of 
simple  hypertrophy,  as  in  leukaemia ;  the  amyloid  condition 
is,  as  a  rule,  the  most  dense,  and  often  associated  with  en- 
largement of  the  spleen  and  albuminuria.  If,  on  the  con- 
trary, the  surface  of  the  organ  is  irregular,  nodules  of  varying 
size  existing  on  its  surface,  and  in  some  instances  projecting 
beyond  its  lower  edge,  and  especially  if  some  of  these  nodules 
can  be  felt  to  be  depressed  or  umbilicated  in  the  centre,  and 
palpation  elicits  a  degree  of  pain  or  tenderness,  then  there  is 
strong  ground  for  the  suspicion  of  cancerous  disease  of  the 
liver.  If,  however,  the  irregularities  on  the  surface  are 
small,  and  associated  with  symptoms  of  obstruction  to  the 
portal  system,  such  as  ascites,  hemorrhage  from  the  stomach 
or  bowels,  &c.,  then  it  may  be  a  case  of  cirrhosis,  or  "gin 
drinker's  liver,"  although  this  disease  is  not,  as  a  rule, 
attended  by  enlargement,  but  rather  atrophy.  Uniform 
enlargement  is  apt  to  occur  in  all  cases  in  which  there  is 
obstruction  to  the  systemic  circulation  ;  and  so  in  diseases  of 
the  heart,  especially  of  the  right  side,  it  is  a  very  frequent 
fact,  the  constant  congestion  of  the  portal  system  giving  rise 
to  it.     This  may  also  occur  from  persistent  dietetic  excesses. 

But  the  enlargement  may  not  be  uniform,  but  only  involve 


DIMINUTION    IN    SIZE    OF    THE    LIVER.  489 

one  or  other  lobe.  This  is  especially  the  case  in  h^'datid 
disease  and  tropical  abscess.  In  both  these  cases  a  distinct 
tumor  often  exists,  and  if  it  lies  near  the  surface,  fluctuation, 
or  at  least  a  sense  of  elasticity  can  be  felt,  and  in  the  case  of 
the  hydatid  disease  on  percussion  there  is  sometimes  detected 
a  sense  of  tremor  called  "  hydatid  fremitus."  This  is  elicited 
by  laying  tliree  fingers  over  the  seat  of  greatest  distension 
and  percussing  strongly  over  the  middle  finger.  The  affec- 
tions are  differentiated  by  the  grave  constitutional  symptoms 
and  local  tenderness  in  the  case  of  abscess,  and  the  almost 
total  immunity  from  them  in  the  case  of  hydatid  disease. 

With  or  without  enlargement  of  the  liver  there  may  be 
present  a  projection  of  dull  percussion  and  increased  resist- 
ance from  its  under  surface.  If  this  arises  from  the  region 
of  the  gall-bladder,  if  it  conveys  the  sense  of  fluctuation  or 
elasticity,  and  is  pyriform  in  shape  and  tender  to  pressure,  it 
is  most  probably  the  gall-bladder  enlarged  from  obstruction 
to  its  duct.  In  some  instances  gall-stones  are  also  present 
in  the  sac,  and  crepitation  may  be  elicited  sometimes  from 
the  rubbing  of  these  on  each  other.  A  history  of  hepatic 
colic,  and  perhaps  even  the  passage  of  gall-stones,  may 
serve  to  throw  light  on  the  case.  (See  Chapter  xii.,  on 
Jaundice,  p.  332.) 

Diminution  in  the  size  of  the  liver  can  never  be  so  cer- 
tainly stated  as  enlargement,  as  the  area  of  hepatic  dulness  is 
apt  to  be  much  encroached  on  by  emphysematous  lungs  or 
distended  intestine.  But  actual  diminution  in  size  may  take 
place.  This  is  especially  the  case  in  cirrhosis  and  other 
forms  of  chronic  atrophy  and  in  acute  yellow  atrophy  of  the 
liver.  This  latter  condition  is  very  rare,  acute  in  its  course, 
and  associated  with  symptoms  of  great  vital  depression,  and 
the  atrophy  may  be  extreme.  It  occurs  chiefly  in  females, 
and  pregnancy  is  a  predisposing  cause.  In  cirrhosis  the 
atrophy  is  not  extreme,  it  is  not  acute  in  its  course,  and  there 
is  often  a  history  of  spirit  drinking. 

The  presence  or  absence  of  pain  or  tenderness  in  diseases 
of  the  liver  must  be  investigated.  Murchison  makes  it  the 
ground  for  his  division  of  enlargements  of  the  liver  into 
"  painful"  and  '<  painless."  Among  the  "  painless"  we  have 
the  so-called  amyloid  liver,  the  fatty  liver,  hydatid  tumor  of 
the  liver,  and  simple  hypertrophy.  Among  the  ''  painful" 
we  have  congestion,  catarrh  of  the  bile-ducts,  interstitial 
hepatitis,  pyajmic  abscess,  tropical  abscess,  and  cancer.  He 
also  remarks  that  painless  enlargements  are  characterized  by 


490      PHYSICAL    EXAMINATION    OF    THE    ABDOMEN. 

an  absence  of  jaundice  and  ascites,  and  by  a  chronic  course, 
but  in  painful  enlargements  jaundice  and  ascites  are  common 
symptoms,  and  the  progress  is  more  rapid. 

SPLEEN. 

In  the  normal  subject  the  spleen  can  be  detected  by  per- 
cussion only,  as  it  lies  quite  under  cover  of  the  ribs  in  the 
left  hypochondrium,  its  convex  surface  corresponding  Avith 
the  9th,  10th,  and  11th  ribs.  Prior  to  attempting  its  de- 
limitation, it  is  well  to  determine  the  percussion  of  a  line 
passing  from  the  left  axilla  downwards  and  inwards  to  the 
umbilicus.  This  line  will  necessarily  be  oblique,  and  if  re- 
quired it  may  be  curved  to  carry  it  outside  the  areas  of  car- 
diac and  hepatic  dulness,  both  of  which  should  be  defined 
before  attempting  the  percussion  of  the  spleen.  This  line 
will  be  found  to  be  more  or  less  resonant  throughout ;  in  its 
upper  part  pulmonary  resonance  is  obtained ;  and  then  pass- 
ing across  stomach,  colon,  and  small  intestines,  the  differences 
in  the  tympanitic  note  of  these  organs  may  be  more  or  less 
distinctly  realized.  The  presence  of  such  a  resonant  line  re- 
moves various  sources  of  fallacy  from  pleuritic  or  pericardial 
effusions,  pulmonary  condensations,  enlargement  of  the  left 
lobe  of  the  liver,  fluid  or  solid  accumulation  in  the  stomach, 
&c.  Having  determined  this  line,  light  percussion  should  be 
made  backwards  and  downwards  from  it  towards  the  splenic 
region,  till  a  change  in  the  note  is  discovered  ;  the  percus- 
sion should  then  be  carried  down  fi-om  the  axilla  on  to  the 
upper  margin  of  spleen,  or  rather  to  the  point  where  the  lung 
ceases  to  overlap  the  organ  ;  and  percussing  upwards  from 
the  tympanic  abdomen  into  the  hypochondrium,  the  lower 
border  will  be  found  normally  inside  the  costal  arch.  The 
posterior  margin  cannot  be  indicated  with  any  degree  of  cer- 
tainty. In  the  average  subject  this  area  of  dulness  will 
measure  from  two  to  three  inches  in  the  oblique  diameter, 
but  this  dulness  varies  greatly  even  in  normal  conditions, 
and  slight  decrease  or  increase  in  its  size  can  never  be  confi- 
dently stated. 

Enlargement  of  the  spleen  is,  as  a  rule,  almost  entirely 
downwards  and  forwards,  unless  it  is  very  firmly  bound  by 
adhesions  to  the  diaphragm.  Considerable  enlargement  may 
take  place,  and  may  be  detected  by  percussion  alone,  un- 
aided by  palpation,  as  the  organ  lies  so  much  inside  the 
margin  of  the  ribs  as  to  admit  of  considerable  increase  in 


THE    SPLEEN.  491 

bulk  before  it  projects  from  under  the  costal  margin.  JEven 
in  such  cases,  however,  it  is  often  possible  by  pressing  the 
fingers  well  up  under  the  costal  arch  to  make  out  a  sense  of 
tumor  or  increased  resistance.  But  percussion  plays  the 
principal  part  in  the  diagnosis.  When,  however,  the  organ 
passes  below  the  ribs,  palpation  becomes  of  prime  importance, 
and  with  one  hand  in  front  and  the  other  behind,  the  organ 
can  be  grasped  and  tilted  backwards  and  forwards.  The  en- 
largement may  be  so  great  as  to  fill  the  whole  left  side  of  the 
abdomen  down  even  to  the  pubes,  and  the  fact  of  its  being 
spleen  may  be  somewhat  obscure,  but  if  the  enlargement  is 
moderate  there  is  usually  little  difiiculty  in  determining  the 
organ  involved.  A  tumor  arising  from  the  left  hypochon- 
drium,  which  is  superficial  and  mobile,  with  rather  blunt 
edges,  and  with  a  notch  in  its  anterior  border,  can  hardly  be 
anything  else  than  spleen.  The  most  likely  sources  of  fallacy 
are  enlarged  or  floating  kidney,  and  fecal  accumulations  in 
the  splenic  flexure  of  the  colon. 

Tliere  are  certain  conditions  in  which  palpation  can  detect 
the  spleen  when  not  enlarged  but  displaced,  in  certain  de- 
formities of  the  chest,  as  in  rickets,  the  spleen  may  be  thrown 
to  a  greater  or  less  extent  from  under  cover  of  the  ribs,  in  the 
same  way  as  the  liver.  In  like  manner  large  pleural  effusions 
in  the  left  side  of  the  chest  will  depress  the  spleen  and  bring 
it  within  the  reach  of  palpation. 

In  emphysematous  states  of  the  lungs,  or  great  distension 
of  the  intestines  with  gas,  the  splenic  dulness  may  be  much 
encroached  on  and  thus  appear  diminished. 

Causes  of  enlargement Enlarged  spleen  may  arise  from 

passive  congestion  from  obstruction  to  the  portal  system  in 
cirrhosis  of  the  liver ;  active  congestion,  as  in  certain  fevers 
(especially  enteric  and  relapsing),  and  above  all  in  ague; 
and  the  constantly  recurring  congestion  in  this  last  affection 
may  lead  ultimately  to  chronic  enlargement  ("  ague  cake"). 
But  the  increase  in  volume  may  be  due  to  splenic  leukcemia, 
the  diagnosis  being  aided  by  the  discovery  of  increase  in  the 
white  blood  corpuscles  ;  or  it  may  be  from  amyloid  disease, 
in  which  case  the  liver  will  most  probably  also  be  enlarged, 
and  the  urine  will  usually  be  found  to  contain  albumen  from 
a  similar  condition  in  the  kidney.  Colloid  cancer,  inflam- 
mation, and  in  very  rare  cases,  abscess  of  the  spleen  may 
also  lead  to  enlargement.  Embolism  of  the  spleen  may 
lead  to  considerable  enlargement,  and  in  such  cases  friction 
may  sometimes  be  detected  over  the  organ  in  the  early  stage  ; 


492      PHYSICAL    EXAMINATIOX    OF    THE    ABDOMEN. 

in  young  children  of  rachitic  habit  the  organ  is  sometimes 
considerably"  enlarged  as  well  as  displaced. 


Fig.  So. — Various  degrees  of  enlargement  of  the  spleen.  The  lines  indic^J^e 
of  splenic  enlargement  are  copied  exactly  from  "Well,  but  the  percussion  limits 
of  the  heart  and  liver  have  been  somewhat  modified. 


THE  KWXEYS 

lie  so  deep  in  the  lumbar  region,  and  in  such  close  proximity 
to  solid  structures,  that  they  cannot  often  be  marked  out  by 
percussion  in  the  natural  condition  with  anything  like  accu- 
racy. Tlie  patient  should  be  laid  flat  on  his  face,  with  all 
the  lumbar  muscles  well  relaxed  ;  the  tympanitic  note  of  the 
colon  is  realized,  and  the  percussion  carried  backward  to  the 


THE    KIDNEYS.  493 

anterioi"  edge  of  the  kidney.     The  upper  edge  is  approached 
in  a  like  manner,  and  is  usually  situated  on  a  level  with  the 
first  or  second  lumbar  vertebra,  aud  the  anterior  edge  from 
3  to  4  inches  from  the  spine.     It  is  to  be  remembered,  how- 
ever, that  one  or  other  kidney  may  be  absent  altogether,  or 
atrophied  from  calculus,  or  may  occupy  some  other  position. 
Slight  degrees  of  enlargement  cannot  be  determined  by  pal- 
pation and  percussion,  especially  if  the  patient  is  fat  and  the 
abdominal  walls  resistant  ;  and  in  most  cases,  indeed,  the 
physical  examination  of  the  kidney  is  quite  secondary  to  the 
careful  examination  of  the  urine.     There  are  cases,  however, 
in  which  positive  results  can  be  got.     Thus  in  cystic  disease, 
or  Hydro-  or  Pyo-nephrosis,  increased  dull  percussion   and 
sense  of  tumor,  or  at  least  resistance,  can  be  made  out.     The 
way  to  detect  this  increased  resistance,  or  sense  of  weight  in 
the  flanks,  is  to  lay  the  patient  flat  on  his   back  with  the 
muscles  quite  relaxed ;  we  then  apply  a  hand  to  either  lum- 
bar region,  and  weigh  the  one  against  the  other,  when,  if  the 
case  is  at  all  well  marked,  there  will  be  little  difliculty  in 
fixing  on  the  heavier  or   more  resistant.     Sometimes,  also, 
there  may  be  distinct  bulging.     Having  determined  this,  the 
affected  flank  is  grasped  between  the  two  hands,  one  in  front 
and  one  behind,  and  sometimes  the  enlarged  kidney  can  be 
felt,  and  the  sense  of  impact  made  out  on  moving  it  from  the 
one  hand  to  the  other.     In  cases  of  cystic  disease,  or  Hydro- 
or  Pyo-nephrosis,  the  organ   may  be   greatly  distended,  dis- 
tinctly fluctuant,  or  at  least  elastic,  and  it  might  be   con- 
founded   with    ovarian   cyst,    hydatid    disease,    or    lumbar 
abscess ;  but  its  renal  nature  can  usually  be  made  out,  and 
there  may  be  elements  in  the  urine  to  guide  the   diagnosis. 
If  it  is  from  calculus  in  the  ureter,  perhaps  there  may  be  a 
former  history  of  a  like  tumor  relieved  by  a  sudden  and 
large  discharge  of  urine,  and  symptoms  of  renal  colic  may 
have  preceded  the  formation  of  the  tumor.     In  Pyo-nephro- 
sis, also,  it  sometimes  happens  tliat  there  is  a   history  of  a 
similar  large  discharge  of  pus,  with  subsidence  of  the  tumor  ; 
or  at  least  variations  in  the  quantity  of  pus  excreted  in  the 
urine  may  occur,  and  this  may  guide  the   diagnosis.     The 
kidney  may  also  be  enlarged  from  cancerous,  sarcomatous,  or 
hydatid  disease.     Perinephritic  abscess  may  simulate  renal 
tumor,  but  can  be  usually  distinguished  on  account  of  its 
affecting  the  psoas  muscle  as  indicated  by  flexion  of  the  thigh 
on  the  pelvis. 

The  kidney  may  become   displaced.     Floating  kidney  is 
42 


494      PHYSICAL    EXAMINATION    OF    THE    ABDOMEN. 

not  always  easy  of  diagnosis,  but  if  there  is  an  abdominal 
tumor  in  the  abdominal  region,  smooth,  ovoid,  presenting  the 
characters  of  the  kidney,  freely  movable,  capable  of  being 
replaced  into  one  or  other  renal  region,  tender  to  pressure, 
but  unattended  by  serious  constitutional  disturbance,  then 
the  suspicion  of  floating  kidney  should  be  entertained ;  this 
is  all  the  more  likely  if  we  can  determine  the  absence  of 
either  kidney  in  the  lumbar  region. 

PANCREAS. 

In  the  healthy  condition,  physical  diagnosis  fails  to  detect 
the  pancreas,  or  at  least  to  give  data  of  any  importance  ;  but 
■when  it  is  the  seat  of  disease  (chiefly  cancerous),  and  the 
patient  is  emaciated,  it  may  come  to  present  a  palpable 
tumor,  lying  across  the  upper  part  of  the  abdomen,  chiefly 
in  the  epigastrium,  very  deep,  and  often  receiving  an  im- 
pulse from  the  aorta  or  superior  mesenteric  artery.  It  is 
likely  to  be  confounded  with  aneurism,  but  the  pulsation 
may  be  determined  to  be  not  expansile,  being  simply  a  heave 
communicated  to  the  tumor  from  the  vessel.  It  may  also  be 
confused  with  other  deep  tumors,  and  in  such  cases  the  diag- 
nosis can  only  be  inferential.  Tumors  in  the  stomach  may 
also  be  mistaken  for  it,  but  these  are  usually  more  super- 
ficial, more  mobile,  and  often  obey  the  respiratory  movements 
of  the  diaphragm.  The  appearance  of  fatty  matter  in  the 
stools  is  presumptive  evidence  of  disease  of  the  pancreas. 
Jaundice  may  be  present  in  some  cases  of  disease  of  the 
head  of  the  pancreas  from  pressure  on  the  bile-duct. 

THE  STOMACH 

will  usually  be  found  to  occupy  the  epigastric  and  part  of  the 
left  hypochondriac  regions,  but  its  position  is  subject  to  great 
variation  according  to  its  state  of  distension  and  the  con- 
dition of  surrounding  organs,  its  mobility  allowing  of  much 
displacement.  If  the  left  lobe  of  the  liver  is  enlarged,  the 
stomach  may  be  pushed  down  into  the  umbilical  region  ;  and 
ownng  to  ascites,  abdominal  tumors,  &c.,  it  may  be  pushed 
up  so  as  to  lie  much  under  the  cover  of  the  ribs.  In  retrac- 
tion of  the  left  lung  in  phthisis,  it  may  be  dragged  up  into 
the  left  lateral  region,  and  in  extreme  cases  may  be  found 
high  up  in  the  axilla. 

The  stomach  may  become  enormously  distended.  This  most 


THE    STOMACH.  495 

frequently  happens  in  stricture  of  the  pylorus  (simple  or 
malignant).  The  distended  organ  may  fill  almost  the  whole 
abdomen,  and  even  encroach  to  some  extent  on  the  chest, 
especially  the  left  side,  but  the  distension  is,  as  a  rule,  dis- 
tinctly related  to  the  epigastric  region.  The  peristaltic 
action  may  sometimes  be  observed  through  the  abdominal 
wall,  and  the  examination  of  the  vomited  matters  may  aid 
in  determining  the  existence  of  dilatation.  (See  p.  311.) 
The  percussion  note  is  highly  tympanitic,  and  the  organ  can 
generally  be  pi-etty  accurately  mapped  out,  if  the  method  of 
auscultatory  percussion,  already  described  (see  p.  484),  is 
employed.  As  there  is  usually  fluid  as  well  as  air  in  the 
organ,  change  in  position  may  alter  the  percussion  limits. 
Thus,  if  the  paient  is  laid  on  his  left  side,  the  fluid  will  gra- 
vitate into  the  "  cul  de  sac."  This  fluid  level  should  be 
carefully  determined  and  marked  in  ink,  and  the  patient 
laid  on  his  back  or  left  side,  when  the  dull  area  will  become 
typanitic,  and  the  dulness  will  shift  to  the  dependent  por- 
tion. If  the  patient  is  placed  on  his  hands  and  knees,  the 
dulness  will  be  transferred  to  the  front,  and  the  lateral  re- 
gion will  be  clear.  If  the  hands  are  placed  on  either  side  of 
the  distended  organ,  and  the  patient  shaken,  the  fluid  will 
be  felt  dasliing  from  the  one  side  to  the  other,  and  the  splash- 
ing sound  is  often  audible  to  the  bystander ;  while,  if  aus- 
cultation is  employed,  Hippocratic  succussion  and  its  metal- 
lic phenomena  are  well  heard.  If  the  quantity  of  fluid  in 
the  stomach  is  considerable,  and  the  fingers  are  depressed 
suddenly  and  sharply  into  the  epigastric  region,  a  sense  of 
their  passage  into  fluid  is  sometimes  apparent. 

As  distended  stomach  often  depends  on  obstruction  at  the 
pylorus,  palpation  should  be  employed  to  see  if  any  undue 
hardness,  resistance,  or  tumor  exists  in  that  region.  The 
pyloric  orifice  in  such  cases  does  not  always  maintain  its 
normal  position ;  it  may  be  displaced  to  a  great  extent,  but 
will  generally  be  found  somewhat  to  the  right  of  the  mesial 
line,  and  in  the  upper  part  of  the  abdomen-  If  cancerous 
disease  of  the  pylorus  exists,  pain  on  palpation  is  usually 
complained  of.  Distension  of  the  stomach  may,  however, 
be  due  to  atony  of  the  muscular  coat. 

But  the  tympanitic  note  over  the  stomach  may  be  replaced 
by  dulness.  This  may  be  quite  absolute  to  superficial  per- 
cussion, but  on  a  stronger  stroke  being  employed  a  trace  of 
the  tympanitic  quality  may  still  be  found.  Associated  with 
this  there  may  be  distinct  resistance  and  hardness  on  palpa- 


496      PHYSICAL    EXAMINATION    OF    THE    ABDOMEN. 

tion,  the  pressure  at  the  same  time  causing  pain.  These 
conditions  are  chiefiy  due  to  tumor  of  the  body  of  the 
stomacli  usually  cancerous  in  its  nature.  Pain  on  pressure 
over  the  stomach,  however,  limited  in  its  area,  and  unasso- 
ciated  with  dull  percussion  or  increased  resistance,  may  be 
due  to  simple  gastric  ulcer.  The  diagnosis  must  rest  on  the 
symptoms. 

THE  INTESTINES 

occupy  the  greater  part  of  the  abdomen.  The  small  intes- 
tines lie  in  the  lower  and  front  part  of  the  cavity.  The 
transverse  colon  crosses  the  upper  part  of  the  umbilical  re- 
gion, and  the  descending  and  ascending  colon  occupy  the 
posterior  parts  of  the  lumbar  regions.  The  "  caput  cfecum 
coli"  lies  in  the  right,  and  the  sigmoid  flexure  in  the  left, 
iliac  region,  but  the  latter  is  usually  overlapped  to  some  ex- 
tent by  the  small  intestine.  Over  the  intestine  the  note  is 
tympanitic,  but  it  varies  in  its  quality  according  to  the  size 
and  state  of  distension  of  the  part.  Normally  the  colon  has 
the  deeper  and  fuller  note.  Areas  of  local  dulness  may  pre- 
sent themselves  at  any  part,  depending  on  accumulation  of 
feces  or  other  substances  in  the  intestines,  tumors  of  the  in- 
testine, or  of  the  glands,  or  of  some  of  the  other  viscera  in 
the  abdomen  ;  or  the  whole  area  of  intestinal  percussion  may 
become  more  or  less  dull  owing  to  morbid  deposits  in  the 
peritoneum  and  omentum  (tubercular  or  cancerous  peritoni- 
tis), large  tumors  of  the  solid  organs,  effusion  of  fluid  into 
the  peritoneum,  &c.  On  the  other  hand  the  intestines  may 
become  much  inflated  with  gas  and  render  the  abdomen 
large,  prominent,  and  unduly  tympanitic,  constituting  what 
is  known  as  '■^Tympanites."  This  condition  arises  in  many 
instances  from  obstruction  in  some  part  of  the  canal  (intus- 
susceptio,  hernia,  constriction  from  bands  of  lympth,  twists 
in  the  gut,  inflammation  in  its  walls,  accumulation  of  feces 
or  foreign  bodies,  cicatrization  of  ulcers,  strictures  simple  or 
cancerous,  &c.)  In  many  cases,  however,  it  is  quite  inde- 
pendent of  obstruction,  being  often  found  in  acute  peritoni- 
tis, in  hysterical  patients,  in  cases  of  dyspepsia  where  the 
digestive  powers  are  feeble,  in  enteric  fever,  and  in  spinal 
lesions  where  there  is  atony  of  the  muscular  fibre  of  the 
tube.  In  certain  very  rare  cases  the  tympanites  may  arise 
from  accumulation  of  gas  in  the  peritoneal  cavity. 

In  tympanites  the  abdomen   is  well   projected   in  front, 


ABDOMINAL    SWELLINGS.  497 

spherical,  everywhere  unduly  resonant  (unless  the  dist^nsiou 
is  extreme,  when  it  may  become  somewhat  dull),  and  the 
coils  of  intestine  may  be  defined  through  the  abdominal 
walls,  and  peristaltic  action  observed  in  them.  If  the  dis- 
tension depends  on  obstruction  the  degree  and  distribution  of 
the  tympanites  may  to  a  certain  extent  guide  the  observer 
to  tlie  seat  of  lesion.  If  it  is  low  down  (in  the  rectum  or 
sigmoid  flexure)  the  distension  will  be  found  to  occupy  not 
only  the  anterior  parts  of  the  abdomen  but  also  the  flanks, 
the  inflated  colon  bulging  tlie  lumbar  regions.  But  the  ob- 
struction may  exist  at  the  ileo-cnscal  valve,  and  in  such  cases 
the  swelling  will  occupy  chiefly  the  umbilical  and  lower  parts 
of  abdomen,  there  being  no  great  distension  in  the  lateral 
region,  and  notably  no  bulging  in  the  flanks. 

ASCITES 

is  often  present  in  diseased  conditions  of  the  abdominal 
organs,  more  especially  of  the  liver.  The  quantity  of  fluid 
in  the  peritoneum  varies  greatly  in  difi^erent  cases,  but  wlien 
it  is  so  abundant  as  to  fill  nearly  the  whole  abdominal  sac,  it 
gives  the  belly  a  somewliat  spherical  shape,  causes  the  um- 
bilicus to  protrude,  and  yields  a  uniformly  dull  note  on  per- 
cussion, except  perhajjs  near  the  xiphoid  cartilage,  where 
the  resonance  of  the  stomach  and  intestines  may  be  detected. 
"When  the  patient  is  laid  on  his  back  the  gravitation  of  the 
fluid  causes  the  flanks  to  bulge,  while  the  anterior  part  of  the 
abdomen  becomes  less  prominent.  The  abdominal  walls  are 
tense  and  resistent,  and  the  veins  on  the  surface  are  often 
enlarged  and  tortuous,  owing  to  the  pressure  on  the  large 
venous  trunks  in  the  abdomen.  If  the  fluid  effiision  is  mode- 
rate in  quantity,  the  normal  tympanitic  note  is  retained  in 
the  higher  parts,  owing  to  the  floating  up  of  the  intestines. 
In  such  cases  the  fluid,  if  not  cooped  up  by  adhesions, 
w^ill  be  found  to  obey  the  law  of  fluid  level.  Thus  if  the 
patient  is  laid  on  his  right  side,  the  left  side  of  the  abdomen 
will  yield  a  resonant  note,  while  tlie  right  is  dull.  The  limit 
of  the  dulness  should  be  marked,  and  the  patient  laid  on  his 
left  side,  when  the  conditions  will  be  reversed.  If  laid  on 
his  back  tlie  flanks  are  dull  and  the  anterior  parts  resonant 
(compare  Fig.  40,  p.  340)  ;  and  if  he  sits  up,  the  fluid  gravi- 
tates into  the  hypogastrium.  In  cases  where  the  quantity  of 
fluid  is  small  and  doubt  exists  as  to  its  presence,  the  patient 
should  be  placed  on  his  elbows  and  knees,  and  if  the  fluid  is 

42* 


498      PHYSICAL    EXAMINATION    OF    THE    ABDOMEN 

free  tl)e  most  dependent  part  will  then  give  a  dull  note  in 
the  umbilical  region. 

Another  very  valuable  sign,  when  the  fluid  is  in  .sufficient 
quantity,  is  fluctuation.  To  apply  this  test  the  patient  should 
be  laid  on  his  back.  The  observer  should  then  place  a  hand 
on  one  side  of  the  abdomen,  and  with  the  fingers  of  the  otlier 
tap  firmly,  but  not  too  strongly,  on  the  opposite  side,  and  in 
many  instances  the  fluid  wave  is  felt  to  be  clearly  trans- 
mitted. But  the  wave  may  not  be  got  in  this  particular 
region,  and  it  is  well  in  all  cases  to  try  it  in  others,  as  with 
the  hand  in  the  umbilical  region  while  the  tap  is  delivered 
on  either  side.  There  is  a  danger  of  fallacy  in  this  fluctua- 
tion test  against  which  the  student  must  be  on  his  guard,  for 
in  cases  where  the  abdominal  walls  are  very  tense  (as  in 
tympanites),  or  loaded  with  fat,  a  tremor  is  communicated 
very  like  fluctuation.  Careful  attention  to  other  points  will 
usually  prevent  this  mistake.  Large  dropsical  effusion  into 
the  cellular  tissue  of  the  abdominal  wall  may  render  fluctua- 
tion verv"  obscure,  or  abolish  it  altogether. 

Fluid  may  exist  in  the  peritoneal  cavity,  and  yet  not  obey 
the  law  of  gi-avitation — the  inference  being  that  it  is  confined 
by  adhesions.  The  most  frequent  causes  of  this  are  tuber- 
cular and  cancerous  diseases  of  the  peritoneum,  which,  by 
matting  the  intestines  together,  coop  up  the  fluid.  The  fluc- 
tuation test,  liowever,  may  remain  distinct,  though  never 
present  to  the  same  degree  as  in  simple  ascites,  for  there  are 
changes  induced  in  solid  parts  which  obscure  the  wave.  In 
many  cases,  also,  the  resistance  to  palpation,  owing  to  thick- 
ening of  the  peritoneum  and  omentum,  can  be  verified  ;  and, 
as  the  thickened  mass  lies  in  front  of  the  small  intestine,  we 
are  able  to  judge  to  some  extent  of  its  thickness  by  percus- 
sion ;  the  percussion  note,  when  the  thickening  is  not  great, 
is  superficially  dull,  while  to  a  stronger  stroke  it  is  tympa- 
nitic. In  tubercular  cases,  which  occur  chiefly  in  children, 
the  fluid  may  be  absorbed,  and  the  thickened  and  retracted 
omentum  may  be  realized  by  pjalpation  as  it  passes  across  the 
abdomen  below  the  stomach. 

The  conditions  most  likely  to  be  confused  with  ascites  are 
ovarian  or  parovarian  cysts,  hydatid  disease  of  the  liver  or 
the  peritoneum,  distended  bladder,  and  pjhantom  tumor. 


ABDOMINAL    TUMORS.  499 


OVARIAN  TUMORS  AND  CYSTS. 

This  is  a  condition  very  apt  to  be  confounded  with  ascites, 
especially  if  the  cyst  is  unilocular,  or  has  one  or  two  com- 
partments developed  out  of  all  proportion  to  the  others.  In 
most  cases  the  history  is  an  important  guide.  The  growth 
may  have  been  first  discovered  as  a  small  painless  tumor  in 
one  or  other  iliac  region,  having  gradually  extended  across 
the  abdomen.  The  abdomen  is  well  projected  in  front,  and 
not  bulged  in  the  flanks  as  in  ascites,  and  the  umbilicus  is 
rarely  protruded.  The  percussion  dulness  is  in  the  anterior 
part  of  the  abdomen  as  the  cyst  expands  up  in  front  of  the 
intestines,  and  pushes  them  backwards  and  upwards.  (Com- 
pare Fig.  41,  p.  3-11.) 

Tympanitic  percussion  is  thus  got  in  the  flanks,  and  alter- 
ations in  the  position  of  the  patient  do  not  change  materially 
the  relations  of  the  dull  and  tympanitic  areas.  This  is  evi- 
dence that  the  fluid  is  not  free.  Fluctuation  is  common  in 
ovarian  cyst,  but  it  may  be  vague,  palpation  giving  more  the 
sense  of  elasticity,  and  in  some  cases  solid  matter  can  be  de- 
tected at  various  parts  of  the  tumor.  On  vaginal  examina- 
tion, the  uterus  may  be  found  normal  in  size,  but  high  up  in 
the  pelvis,  and  perhaps  displaced  forward.  In  some  cases  the 
finger  in  the  rectum  can  determine  the  relation  of  the  tumor 
to  the  ovary,  or  its  immediate  vicinity;  and  examination 
with  the  uterine  sound  fails  to  show  any  direct  connection 
with  the  womb.     (See  p.  420,  &c.) 

In  many  instances,  however,  ovarian  cysts  are  accompa- 
nied by  fluid  eflTusion  into  the  peritoneum,  and  the  diagnosis 
may  only  be  made  clear  by  tapping  and  examination  of  the 
fluid  withdrawn.     (See  p.  846.) 

OTHER  ABDOMINAL  TUMORS. 

An  ovarian  cyst  may  be  simulated  by  solid  tumors  of  the 
ovaries  or  uterus,  and  even  the  gravid  uterus  has  been  mis- 
taken for  it.  The  careful  application  of  auscultation  will 
usually  determine  the  diagnosis  of  pregnancy,  and  solid  ute- 
rine tumors  may  be  distinguished  by  their  density,  by  their 
relations  to  the  uterus,  especially  when  examined  by  the 
uterine  sound,  by  the  elongation  of  its  cavity,  and  an  increase 
in  its  size  and  weight.     (For  details  see  p.  420,  &c.) 

A  distended  bladder  might  also  be  a  source  of  confusion, 
but  its  growing  out  of  the  pelvis,  fairly  in  the  middle  line, 


500      PHYSICAL    EXAMINATION    OF    THE    ABDOMEN. 

and  being  pyriform  in  shape,  and  often  tender  on  pressure, 
would  probably  raise  such  doubt  as  to  lead  to  the  introduc- 
tion of  a  long  flexible  catheter,  when  the  tumor  will  dis- 
appear. 

Hydatid  disease  of  the  liver  may  enlarge  so  greatly  as  to 
fill  the  whole  abdomen,  but  the  history  of  growth  from  the 
right  hypochondrium  will  often  be  quite  clear,  and  the 
hydatid  fremitus  may  be  present.  Hydatid  disease  of  tlie 
peritoneum  or  omentum  may  present  greater  difficulty,  and 
the  diagnosis  from  ascites  or  ovarian  cyst  may  only  be  ar- 
rived at  by  tapping  and  examination  of  the  fluid,  the  pre- 
sence of  hydatids  or  booklets  determining  the  point  at  once. 
Even  in  the  absence  of  these  the  chai'acters  of  the  fluid  may 
give  quite  sufficient  ground  for  the  diagnosis.     (See  p.  346. j 

Phantom  tumor  may  present  difficulties  in  diagnosis.  It 
occurs  almost  exclusively  in  women,  especially  in  those  with 
an  hysterical  tendency,  and  it  may  simulate  almost  any  form 
of  abdominal  enlargement ;  but  the  fact  of  its  liability  to 
vary  in  size  and  shape,  the  tension  of  the  abdominal  walls, 
and  its  disappearance  under  the  influence  of  chloroform,  will 
clear  up  the  diagnosis. 

Aneurism  of  the  Abdominal  Aorta  is  most  common 
in  the  epigastric  and  umbilical  regions,  and  may  be  recog- 
nized as  a  tumor  placed  in  the  length  of  the  artery,  lying  in 
close  apposition  to  the  spine,  but  to  the  left  side,  and  giving 
to  the  hand  the  sensation  of  expansile  pulsation,  in  many 
cases  associated  with  thrill.  On  auscultation  a  murmur 
may  be  heard  coinciding  with  the  expansion  of  the  artery ; 
in  rare  cases  it  may  be  double.  Aneurism  of  any  of  the 
branches  of  the  abdominal  aorta  may  exist,  especially  the 
coeliac  axis  or  superior  mesenteric.  Pulsation  of  the  abdom- 
inal aorta  attended  by  murmur  may  be  present  without 
aneurismal  conditions  (see  p.  263),  but  in  such  cases  there 
is  no  impression  of  a  distinct  tumor  which  pulsates,  and  of  a 
murmur  limited  to  the  tumor  and  not  merely  corresponding 
with  the  ti-ack  of  the  aorta.  Aneurisms  may  be  simulated 
by  tumors  lying  over  the  aorta,  and  having  an  impulse  com- 
municated to  them.  The  diagnosis  rests  chiefly  on  the 
non-expansile  character  of  the  pulsation,  but  in  many  cases 
it  is  quite  uncertain.  Pain  is  often  a  marked  feature  in 
abdominal  aneurism.  It  is  usually  felt  in  the  back,  is  con- 
stant in  character,  as  a  rule,  but  subject  to  violent  exacerba- 
tions, with  extension  of  it  down  along  the  sacral  and  lumbar 
cords.  Obscure  pain  of  this  character,  apart  even  from 
physical  signs,  should  always  raise  the  question  of  aneurism. 


LOCALITIES    OF    TUMOES.  501 


LOCALITIES  OF  TUMORS. 


Leaving  out  of  consideration  the  general  enlargements  of 
the  abdomen  due  to  ascites  and  tympanites,  it  may  be  well 
to  indicate  briefly  a  few  facts  with  regard  to  local  enlarge- 
ments or  tumors.  A  tumor  being  discovered  in  the  abdomen, 
the  whole  physical  inquiry  hinges  on  the  question.  What 
organ  or  structure  is  it  connected  with  ?  In  such  an  inquiry 
it  is  of  prime  importance  to  consider  the  regional  divisions  of 
the  abdomen  mentioned  in  the  early  part  of  this  section,  and 
the  organs  contained  in  them.  If  the  tumor  is  confined 
entirely  or  chiefly  to  one  of  these  regions,  then  the  various 
organs  must  be  gone  over  in  detail  to  see  from  which  it 
springs.  In  serious  diseases,  however,  the  abdominal  organs 
may  be  greatly  displaced  from  their  ordinary  position.  It 
will  suffice  for  our  purpose  to  indicate  what  tumors  are  most 
frequent  in  the  various  regions. 

In  the  epigastric  region  the  tumors  most  frequently  met 
with  are  cancerous  disease  of  the  pylorus  or  body  of  the 
stomach,  enlargements  of  the  left  lobe  of  the  liver,  tumors  of 
the  pancreas,  and  aneurisms  of  the  aorta.  It  is  to  be  re- 
membered that  the  left  lobe  of  the  liver  may  present  itself  as 
a  tumor  without  there  being  any  enlargement  of  it,  condi- 
tions in  the  thoracic  viscera  having  depressed  the  organ. 
This  fallacy  is  to  be  guarded  against,  and  the  same  remark 
applies  to  the  liver  in  the  right  hypochondrium  and  to  the 
spleen  in  the  left. 

The  tumors  met  with  in  the  umbilical  region  are  aneur- 
isms of  the  aorta  and  omental  tumors,  fecal  accumulations  in 
the  transverse  colon,  and  at  times  cancer  of  the  intestine  and 
enlarged  mesenteric  glands.  Fecal  accumulations  may  occur 
even  with  a  history  of  diarrhoea.  Through  the  abdominal 
wall  they  can  be  moulded  to  some  extent  by  steady  pressure 
with  the  fingers,  and  may  be  even  displaced  a  little  along 
the  bowel. 

Tumors  originating  in  the  hypogastric  region,  are  dis- 
tended bladder,  the  gravid  uterus,  tumors  of  the  womb,  and 
inflammatory  growths  in  the  pelvis. 

Those  originating  in  the  right  hypochondrium,  are  chiefly 
from  the  right  lobe  of  the  liver  or  gall-bladder. 

In  the  left  hypochondrium,  the  spleen  is  the  organ  chiefly 
affected,  although  fecal  accumulations  in  the  splenic  flexure 
may  occur. 

In  the  lumbar  regions,  tumors  of  the  kidney,  perinephritic 


502      PHYSICAL    EXAMINATION    OP    THE    ABDOMEN. 

abscess,  lumbar  abscess,  and  fecal  accumulations  are  most 
frequent. 

In  the  iliac  regions,  ovarian  cyst,  pelvic  abscess,  disease  of 
ca3cum  or  sigmoid  flexure,  enlarged  glands,  pelvic  cellulitis 
or  hosmatocele  are  found. 

It  is  rare,  however,  for  tumors  to  occupy  only  the  region 
from  which  they  spring.  They  often  involve  several ;  and 
it  is  only  by  a  careful  consideration  of  the  history  and  symp- 
toms, along  with  the  physical  signs,  that  a  diagnosis  can  be 
arrived  at.  In  not  a  few  instances  several  organs  may  be 
affected,  and  this  renders  the  examination  all  the  more  per- 
plexing. In  many  cases  the  most  critical  exploration  will 
fail  to  resolve  the  doubts. 


503 


CHAPTER  XYII. 

METHOD  OF  PERFOKMIXG  POST-MORTEM 
EXAillNATIONS. 

In  performing  post-mortem  examinations  it  is  of  conse- 
quence to  get  into  a  habit  of  going  through  the  various  ope- 
rations in  a  systematic  way.  It  is  only  thus  we  can  insure 
that  nothing  of  primary  importance  is  overlooked.  Xot  that 
it  is  necessary  to  be  the  slave  of  any  particular  system,  but 
that  the  thing  should  be  done  on  a  certain  plan,  any  devia- 
tions that  are  called  for  being  made,  but  at  the  same  time 
recognized  as  deviations,  and  the  regular  course  resumed  as 
soon  as  possible. 

Instruments  and  Method The  instruments  required 

are  comparatively  few.  The  first  is  a  good  stout  knife,  such 
as  that  used  in  Syme's  amputation.  Then  one  or  two  scalpels 
and  dissecting  forceps,  a  pair  of  gut  scissors,  and  a  pair  of 
strong  probe-pointed  scissors^  are  required.  A  saw,  chisel, 
and  hammer  or  wooden  mallet  (better  the  latter),  a  probe,  a 
dissecting  needle,  and  a  cartilage-knife,  complete  the  ordinary 
equipment.  The  cartilage-knife  should  have  a  triangular 
blade,  the  edoje  beino;  straiorht,  and  forming  an  angle  of  about 

7  DOC'  DC 

35°  with  the  back,  which  should  be  very  strong  and  thick. 
This  knife  is  seldom  satisfactorily  made ;  it  should  have  a 
back  like  a  razor,  but  be  ground  to  the  shape  described. 

The  first  lesson  the  student  has  to  learn  is  to  hold  the 
knife  properly,  and  he  should  remember  that  what  is  wanted 
is  not  a  dissection  of  each  muscle  and  nerve,  but  a  rapid 
and  comprehensive  survey  of  each  organ  in  the  body.  The 
knife  must  therefore  be  held  so  that  full,  sweeping  strokes 
may  be  made  with  it.  The  handle  should  be  grasped  firmly 
in  the  closed  fist,  the  edge  of  the  blade  corresponding  with 
the  palmar  aspect  of  the  hand,  not  held  delicately  like  a  pen 
or  a  dissecting-knife.     Again,  in  cutting,  the  belly  of  the 

'  I  have  found  some  difficulty  in  getting  from  the  instrument- 
maker  these  probe-pointed  scissors,  but  as  they  are  of  great  use 
they  should  be  specially  ordered. 


504  POST-MORTEM    EXAMINATIONS. 

knife  should  be  used,  and  not  merely  the  point  as  in  dissect- 
ing. This  is  a  matter  which  it  is  very  difficult  to  get  stu- 
dents to  appreciate,  and  it  is  very  important,  both  on 
account  of  the  saving  of  time,  which  a  proper  method  in- 
volves, and  also  because  a  good  clean  cut  exposes  the  struc- 
tures to  be  examined  veiy  much  better  than  an  imperfect, 
half-tearing  one.  Let  the  knife  be  grasped  firmly,  and  learn 
to  make  the  incisions  with  the  whole  weight  of  the  arm,  and, 
if  necessary,  of  the  body,  the  wrist  being  kept  rigid. 

It  may  here  be  remarked  that  in  the  following  description 
the  writer  has  simply  imagined  himself  to  be  making  a  post- 
mortem examination,  and  has  endeavored  to  set  down  the 
various  operations  which  he  is  in  the  habit  of  performing. 
If  the  student  in  reading  the  description  will  imagine  that 
he  has  the  knife  in  his  hand,  and  will  follow  each  step  as  if 
he  were  himself  engaged,  it  is  believed  that  the  account  will 
be  read  with  greater  intelligence,  and  be  much  better  im- 
pressed on  the  mind.  It  should  be  added  that  in  the  use  of 
such  terms  as  anterior,  external,  or  their  English  equiva- 
lents, in  front,  behind,  outside,  and  so  on,  the  strictly  ana- 
tomical signification  is  preserved.  As  the  body  during  the 
greater  part  of  the  examination  lies  on  its  back,  there  is  a 
great  temptation  to  depart  from  this,  and  call  the  anatomical 
anterior  and  posterior  the  upper  and  under,  but  confusion 
will  only  be  avoided  l)y  adhering  closely  to  the  anatomical 
significations. 

A  report  of  the  facts  observed  should  always  be  dictated 
during  the  course  of  the  post-mortem,  and  with  the  structures 
before  you.  This  is  a  matter  of  very  great  importance,  be- 
cause, on  the  one  hand,  the  facts  may  be  otherwise  forgotten, 
and  on  the  other  hand,  the  mere  act  of  dictating  a  note  in- 
duces one  to  make  the  observation  much  more  accurate,  and 
often  suggests  investigations  which  would  otherwise  be  over- 
looked. 

As  the  body  lies  on  the  table  certain  general  appearances 
should  first  be  observed  and  noted,  such  as  the  state  of 
rigidity  as  determined  by  trying  to  bend  the  limbs;  the 
evidences  of  decomposition  ;  the  color  of  the  surface,  whether 
unduly  pale  or  red  or  livid ;  the  presence  or  absence  of 
oedema,  any  wounds  or  cicatrices.  The  general  state  of 
nutrition  will  also  be  observed,  and,  in  connection  with  this, 
the  comparative  abundance  of  the  subcutaneous  fat  as  dis- 
played by  the  first  incision.  In  case  of  a  medico-legal 
examination  the  body  has  to  be  identified  by  two  persons 


CHEST,  505 

whose  names  and  connection  with  the  deceased  should  be 
noted;  the  size,  position,  depth,  and  condition  of  any  wound 
will  also  be  carefully  observed,  and  incisions  will  be  judi- 
ciously made  so  as  to  display  the  wound  thorouahly ;  or  dis- 
sections will  be  vmdertuken  so  as  to  trace  its  relations  to  impor- 
tant structures.  The  examination  of  the  surface  of  the  body 
will  not  be  confined  in  every  case  to  its  anterior  aspect. 

As  the  chest  and  abdomen  are  most  frequently  examined, 
we  shall  begin  with  them.  A  substantial  block  of  wood  is 
placed  under  tlie  body  so  as  to  support  the  chest  and  increase 
the  anterior  convexity  of  the  sternum.  The  knife  being  now 
grasped  in  the  fist,  an  incision  is  made  with  a  single  sweep 
from  the  suprastei'nal  notch  to  the  sjonphysis  pubis,  de- 
viating slightly  in  the  abdomen  to  avoid  the  umbilicus. 

Chest. — Beginning  in  the  chest  the  knife  penetrates 
through  the  soft  parts  right  down  to  the  sternum,  and  on 
passing  to  the  abdomen  a  similar  depth  is  kept.  In  this 
first  incision  the  aVxlominal  cavity  may  perhaps  be  opened 
into,  but  if  the  knife  has  not  penetrated  so  deeply  the  next 
procedure  is  to  open  it  through  the  entire  length  of  the  in- 
cision in  the  abdomen.  By  dragging  on  the  edge  of  the 
incision  and  cutting  against  the  tightly  drawn  tissues,  it  is 
easy  to  lay  open  the  cavity  without  cutting  any  of  the  sub- 
jacent viscera.  This  being  done  we  have  an  incision  extend- 
ing in  the  middle  line  along  the  entire  thorax  and  abdomen, 
and  penetrating  down  to  the  sternum  in  the  first  part  of  its 
course,  and  afterwards  through  the  peritoneum.  If  any 
fluid  is  pi-esent  in  the  peritoneal  cavity  its  quantity  and 
character  will  be  noted  at  this  stage. 

The  next  step  is  to  reflect  the  soft  parts  from  the  anterior 
aspect  of  the  thorax,  and  in  this  operation,  as  in  many  others, 
it  is  important  to  remember  that  if  the  tissues  are  dragged 
upon  and  thus  rendered  tense,  they  are  much  more  easilv 
divided  than  when  lax.  For  this  reason  it  is  well  to  begin 
at  the  lower  part  of  the  thorax,  because  here  the  left  liand 
may  obtain  a  firm  hold  of  the  abdominal  parietes  and  pull 
the  tissues  firmly  outwards  against  the  false  ribs.  By  a  few 
sweeping  strokes  against  the  tense  tissues,  the  anterior  wall 
of  the  thorax  is  exposed.  It  is  to  be  observed  that  the  soft 
parts  should  be  reflected  much  further  back  at  the  lower  part 
of  the  thorax  than  at  the  upper,  in  order  fully  .to  expose  the 
cartilaginous  ribs,  which  are  longer  below  than  above.  Be- 
fore dividing  the  cartilaginous  ribs,  it  will  be  well  for  the 
beginner  just  to  observe  the  line  of  junction  of  the  cartilao-i- 
43 


506  POST-MORTEM    EXAMINATIONS. 

nous  and  osseous  ribs  from  nbove  downwards.  Beginning 
Avith  the  second  rib  the  cartilages  are  to  be  divided  just 
within  the  line  of  junction,  and  it  will  be  seen  that  the  in- 
cision tends  very  considerably  outwards  in  passing  down  the 
thorax.  In  dividing  tlie  cartilages  the  edge  of  the  cartilage- 
knife  should  be  held  flat  against  the  thorax,  so  that  before 
one  cartilage  is  fully  divided  the  knife  will  have  caught  on 
the  next  succeeding  one.  If  this  be  attended  to,  the  sub- 
jacent organs  will  not  be  injured.  There  still  remain  to  be 
divided  the  first  rib,  and  the  sterno-clavicular  articulation  ; 
the  latter  is  often  a  stumbling  block  to  beginners.  The 
clavicle  is  united  to  the  sternum  and  to  the  first  rib  by  firm 
ligaments,  and  it  is  necessary  to  cut  these  through  in  order 
to  free  the  anterior  wall  of  the  thorax.  The  head  of  the 
clavicle  should  be  found,  and  a  pointed  knife  (the  cartilage- 
knife  should  have  a  triangular  blade  for  this  purpose),  held 
perpendicularly  to  the  surface  of  the  body,  is  made  to  pene- 
trate the  joint  immediately  to  the  inner  side  of  the  head  of 
the  clavicle.  It  is  then  pushed  downwards  towards  the 
thorax  with  a  slight  inclination  outwards  so  as  to  divide  the 
sterno-clavicular  ligaments.  It  is  afterwards  worked  round 
the  head  of  the  clavicle  and  carried  outwards  so  as  to  divide 
the  strong  ligament  between  the  clavicle  and  the  first  rib. 
If  the  position  of  those  ligaments  be  studied  in  such  a  plate 
as  that  in  Quain's  Anatomy,  the  direction  of  the  incisions 
will  readily  be  gathered.  The  cartilage  of  the  first  rib  is 
now  to  be  divided,  and  this  is  best  done  by  introducing  the 
knife  between  the  first  and  second  ribs  and  cutting  through 
the  former  right  against  the  clavicle.  It  should  be  remem- 
bered that  on  account  of  the  breadth  of  the  manubrium 
sterni  this  cartilage  is  further  out  than  the  second.  In  this 
way  the  sternum  and  cartilaginous  ribs  are  separated  from 
all  but  soft  attachments,  and  these  have  now  to  be  divided. 
Seizing  the  lower  cartilaginous  ribs  with  the  left  hand  and 
dragging  sternum  and  cartilages  forwards,  the  anterior  at- 
tachments of  the  diaphragm  are  cut  through,  and  then  in 
succession  all  other  attachments  from  below  upwards,  keep- 
ing close  to  the  bone,  especially  at  the  upper  part,  so  as  to 
avoid  wounding  the  large  veins  at  the  root  of  the  neck.  The 
condition  of  the  ribs  and  sternum  will  be  observed,  before 
they  are  set  aside.  It  is  sometimes  necessary  to  modify  this 
procedure  on  account  of  the  cartilages  being  calcified  and 
almost  like  bone.  In  every  case  they  should,  if  possible,  be 
divided  with  the  knife,  and  this  method  will  rarely  fail  even 


HEART.  507 

tliougli  the  cartilage  be  very  hard.  But  sometmies.  it  is 
necessary  to  saw  through  the  cartilages,  the  other  parts  of 
the  operation  being  the  same  as  those  already  described. 

The  contents  of  the  thorax  are  then  exposed,  and  the 
general  position  of  the  edges  of  the  lungs  and  of  the  peri- 
cardium and  heart  should  be  noticed.  Before  going  further 
the  contents  of  the  pleural  cavities  should  now  be  examined. 
The  pericardium  is  then  to  be  opened,  and  this  may  be 
done  by  taking  hold  of  it  with  the  left  hand,  pulling  it  till  the 
tissue  is  tense,  and  then  dividing  it  by  an  oblique  incision 
so  as  not  to  incise  the  heart  beneath,  formally  there  is  a 
small  quantity  of  fluid  in  the  sac. of  the  pericardium  ;  any 
excess  above  three  or  four  drachms  will  be  noted.  Before 
removing  the  heart  from  the  body  it  is  well  to  make  incis- 
ions into  its  cavities  in  order  to  determine  the  quantity  of 
blood  in  them.  These  incisions  are  made  along  the  left  and 
right  borders  of  the  heart  respectively,  and  into  its  four 
cavities,  the  boundary  line  bet\veen  the  auricles  and  ventri- 
cles being  spared.  There  will  thus  be  four  incisions,  viz., 
into  the  left  auricle,  left  ventricle,  right  auricle,  and  right 
ventricle,  and  the  incisions  will  be  longitudinal,  passing  in  a 
direction  from  base  to  ajjex.  In  making  tlie  incisions  the 
apex  of  the  heart  should  be  seized  with  the  left  hand,  and 
dragged  well  forwards  out  of  the  body,  so  as  to  make  the 
structures  tense.  After  these  incisions  the  fingers  may  be 
introduced  into  the  cavities,  and  the  contents  approximately 
determined.  The  heart  will  then  be  removed.  It  should 
be  seized  by  the  apex  and  dragged  well  out  of  the  body  and 
towards  the  head,  and  the  great  vessels  divided  from  below 
upwards.  Before  proceeding  further  the  sufficiency  of  the 
aortic  and  pulmonary  valves  should  be  tested.  These  ves- 
sels should  first  be  cleared  of  any  adhering  blood-clot,  and 
then  a  stream  of  water  poured  into  them  at  their  cut  extrem- 
ities. The  water  should  be  poured  from  a  height  so  as  to 
pass  in  with  some  force.  If  the  valves  are  competent  then . 
the  vessels  will  be  filled  with  the  water  and  remain  full. 
The  closed  valves  may  be  observed  from  above  through  the 
water,  but  in  order  to  do  this  it  is  sometimes  necessary  to 
cut  the  artery  shorter,  as  the  arch  of  the  vessel  may  interfere 
with  direct  observation. 

The  general  appearance  and  shape  of  the  heart  will  now 
be  observed.  Normally  it  forms  a  blunt  cone,  and  is  nearly 
completely  coated  with  a  layer  of  adipose  tissue  under  the 
pericardium,  which  is  most  abundant  over  the  right  ventricle. 


508  POST- MORTEM    EXAMINATIONS. 

The  cavities  of  tlie  heart  are  now  to  be  laid  open  so  as  to 
expose  the  valves  completely  to  view.  The  heart  should  be 
laid  on  a  plate  resting  on  its  posterior  surface  just  as  it  was 
lying  in  the  body.  Tlie  blunt  blade  of  the  gut  scissors  is 
then  introduced  into  the  right  ventricle  through  the  cut 
already  made,  and  pushed  upwards  into  the  pulmonary 
artery.  If  the  point  be  kept  in  the  angle  between  the 
septum  and  anterior  wall  of  the  ventricle  while  it  is  puslied 
onwards,  it  will  find  its  way  into  the  pulmonary  artery. 
Along  this  line  the  scissors  are  closed,  and  an  incision  made 
from  apex  to  base,  dividing  ventricle  and  pulmonary  artery. 
With  the  former  incision  this  new  one  forms  such  an  ano-le 
as  to  separate  a  triangular  flap  of  ventricle.  A  similar 
method  is  followed  on  the  left  side.  The  blade  is  introduced 
at  the  former  incision,  and  being  held  in  the  angle  between 
septum  and  anterior  wall,  is  carried  out  at  the  aorta.  In 
completing  this  incision  care  is  taken  not  to  cut  the  left 
auricular  appendage,  on  the  one  hand,  or  the  pulmonary 
artery  near  its  oi'igin,  on  the  other.  The  cavities  being  laid 
open  the  state  of  the  valves  will  be  observed,  and  any  vari- 
ation from  the  normal  carefully  regarded.  The  amount  and 
kind  of  clot  in  the  ventricles  will  be  noticed,  and  so  forth. 
The  auricles  are  then  more  fully  laid  open  by  means  of  the 
probe-pointed  scissors,  and  the  contents  observed.  The 
auricular  appendages  should  always  be  opened  up  because 
thrombi  often  lodge  here.  The  capacity  of  the  uriculo-ven- 
tricular  orifices  should  now  be  roughly  estimated,  by  intro- 
ducing the  fingers  from  the  auricles.  The  mitral  orifice 
normally  admits  two  or  three  fingers,  and  the  tricuspid  three 
or  four.  After  all  clot  has  been  removed,  the  heart  should 
be  weighed.  The  normal  weight  in  the  adult  male  is  from 
8  to  11  oz.,  and  in  the  female  7  to  9  oz. 

The  lungs  are  now  to  be  removed,  and  in  order  to  do  this 
they  must  first  be  freed  from  all  pleural  adhesions,  if  such 
exist.  These  adhesions  may  often  be  torn  througli  Avith  the 
fingers,  but  sometimes  they  are  too  firm  for  this.  The  adhe- 
sion is  between  the  visceral  and  costal  layers  of  the  pleura, 
and  it  is  sometimes  easier  to  separate  the  costal  jjleura  from 
the  internal  wall  of  the  thorax  than  to  tear  through  the 
adhesions.  In  order  to  do  this  an  incision  is  made  longitu- 
dinally along  the  internal  aspect  of  the  thorax,  cutting 
against  the  ribs  near  their  anterior  extremities ;  the  fingers 
are  introduced  behind  the  pleura,  which  is  then  torn  off  from 
the  ribs.     The  lungs  being  freed,  the  apex  of  one  is  seized 


LUNGS  —  NECK — ABDOMEN.  509 

and  pulled  downwards  so  as  to  expose  the  root,  which -is  then 
cut  through,  and  the  lung  removed.  By  a  similar  procedure 
the  other  is  taken  out.  The  lungs  being  removed  from  the 
body,  they  are  each  in  turn  to  be  incised  in  such  a  manner 
a^to  expose  their  tissue  thoroughly.  Each  is  held  by  the 
root  with  the  left  hand,  with  its  base  resting  on  a  wooden 
platter,  and  a  cut  made  from  apex  to  base  along  the  most 
convex  part  of  the  surface,  and  carried  down  towards  the 
root.  The  lung  tissue  is  now  examined,  and,  with  the  probe- 
pointed  scissors,  the  bronchial  tubes  opened  up  so  as  to  expose 
the  mucous  membrane  to  view. 

The  structures  of  the  neck  and  what  remains  of  the  aorta 
have  still  to  be  examined.  For  this  purpose,  the  original 
incision  through  the  skin  is  continued  upwards  to  the  chin. 
The  skin  is  reflected  by  sweeping  strokes  of  the  knife,  so  as 
to  expose  the  structures  of  the  neck.  This  being  done,  the 
knife  is  made  to  puncture  the  floor  of  the  mouth  from  below 
near  the  middle  line,  and  carried  backwards  along  the  jaw, 
first  on  one  side  then  on  the  other,  so  as  to  separate  the  floor 
of  the  mouth.  The  fingers  can  tlien  be  introduced,  and  the 
tongue  seized  and  dragged  downwards.  By  pulling  firmly 
on  the  tongue,  the  incisions  can  be  readily  carried  backwai'ds, 
and  the  knife  divides  the  soft  palate  and  then  passes  to  the 
posterior  wall  of  the  pharynx.  The  whole  structures  are 
now  separated  from  the  bodies  of  the  vertebrae,  right  down 
to  the  diaphragm,  where  the  aorta  and  oeeophagus  are  divided 
transversely.  The  parts  being  now  laid  with  their  anterior 
aspect  downwards,  the  scissors  are  made  to  divide  the  pha- 
rynx and  oesophagus  along  their  posterior  wall,  then  the 
larynx  and  trachea,  also  posteriorly,  and  lastly  the  arch  of 
the  aorta  and  its  thoracic  portion. 

Abdomen. — We  now  proceed  to  the  organs  of  the  abdo- 
men. The  block  which  supported  the  thorax  is  removed, 
and  the  diaphragm  is  incised  on  either  side  so  as  to  allow 
the  abdorninal  organs  to  gravitate  towards  the  thorax.  In 
order  to  expose  these  organs  fully,  it  is  necessary  first  to 
separate  the  colon  from  its  attachments,  as  it  lies  in  front  of 
some  of  the  more  important  structures.  The  small  intestine 
is  pulled  aside,  and  carried  half  out  of  the  body,  and  then, 
beginning  at  the  sigmoid  flexure,  the  large  gut  is  pulled  for- 
wards, while  its  attachments,  thus  rendered  tense,  are  cut 
through.  When  the  descending  and  transverse  colon  have 
been  separated,  it  is  often  easier  to  pass  to  the  caput  CEecum, 
and   take   the   ascending  colon   from  below  upwards.     The 

43* 


510  POST-MORTEM    EXAMINATIONS, 

large  intestine  being  separated  but  not  cut  through,  it  is  laid 
out  of  the  body  between  the  legs,  being  still  attached  at  the 
rectum  and  ileum. 

The  position  of  the  organs  is  now  to  be  surveyed,  and  then 
the  kidneys  are  to  be  examined.  They  should  first  be  ob- 
served in  situ,  and  any  distension  of  the  ureters  or  other 
alteration  noted.  The  sup7-a-rencd  capsules  may  be  ex])osed 
at  this  stage,  and  they  should  be  subsequently  removed 
along  with  the  kidneys.  It  should  be  remembered  that  the 
kidney  lies  behind  the  peritoneum,  and  the  first  step  towards 
its  removal  is  to  cut  through  the  peritoneum  to  its  outer  side. 
This  being  done,  the  fingers  can  now  grasp  the  kidney  and 
drag  it  forwards,  and  a  few  incisions  will  separate  it  with  the 
supra-renal  capsule  from  all  attachments.  The  kidney  is 
examined  by  holding  it  in  the  left  hand  with  the  hilus  to- 
wards the  palm,  and  then  making  an  incision  along  the  con- 
vex border,  first  through  the  capsule  and  then  into  the 
kidney  substance  down  to  the  pelvis.  The  whole  depth  of 
the  kidney  tissue  is  thus  exhibited,  and  the  capsule  may  be 
separated  so  as  to  expose  the  surface  by  catching  it  at  the 
edge  of  the  cut  and  tearing  it  off.  Before  weighing  the  or- 
gan, the  supra-renal  capsule  will  be  removed  and  examined, 
and  the  external  fatty  capsule  disposed  of.  The  normal 
weight  of  each  kidney  varies  in  the  adult  male  from  4^  to  6 
oz.,  and  in  the  female  from  4  to  5^  oz. 

The  spleen  is  easily  removed  by  dragging  it  forward  and 
cutting  through  the  vessels.  If  it  is  laid  on  a  plate,  an  in- 
cision along  its  convex  surface  towards  the  hilus  will  expose 
its  tissue.  The  normal  weight  of  this  organ  is  extremely 
variable,  and  may  fluctuate  between  3  or  4  and  7  oz. 

With  a  view  to  the  examination  of  the  stomach  in  situ, 
the  gut  scissors  are  first  used  to  make  an  incision  into  the 
lower  part  of  the  duodenum.  The  long  blade  is  then  intro- 
duced at  this  incision,  and  the  duodenum  and  stomach  di- 
vided, the  latter  along  its  greater  curvature.  The  mucous 
membrane  of  the  stomach  is  examined  by  pulling  the  organ 
well  forward,  and  laying  it  over  the  cut  edges  of  the  ribs. 
The  papilla  forming  the  orifice  of  the  ductus  communis  will 
be  observed  in  the  duodenum,  and  the  permeability  of  the 
ducts  tested  by  forcing  bile  through  them  by  squeezing  the 
gall-bladder.  If  icterus  be  present,  the  ducts  will  be  care- 
fully traced  upwards  to  the  liver. 

In  medico -legal  cases,  where  poisoning  is  suspected,  par- 
ticular care  will  be  required  in  dealing  Avith  the  stomach. 


LIVER  —  INTESTINES.  511 

Before  interfering  with  it  in  any  way,  ligatures  shotild  be 
applied  just  beyond  the  cardiac  and  pyloric  orifices,  and  the 
stomach  carefully  removed  entire.  As  a  rule,  it  should  be 
at  once  placed  in  a  clean  jar,  and  the  jar  covered  with  some 
water-proof  material  fixed  with  a  string,  of  which  the  knot 
will  be  sealed  with  wax.  A  label  will  also  be  attached.  If 
it  is  desirable  to  examine  the  contents  of  the  stomach  at 
once,  the  organ,  after  removal  as  above,  should  be  opened 
on  a  clean  plate,  and  all  its  contents  carefully  preserved. 
Stomach  and  contents  will  then  be  placed  in  a  jar  sealed  and 
labelled  as  above.  The  duodenum  sliould  be  preserved  in  a 
similar  way,  and  afterwards  the  liver  with  the  gall  bladder 
and  the  urinary  bladder,  with  their  contents. 

The  liver  will  be  removed  by  first  cutting  through  the  por- 
tal vessels,  lifting  the  organ  out  of  the  body  till  it  rests  on 
the  ribs,  and  then  dividing  the  diaphragmatic  attachments. 
It  should  now  be  laid  with  the  portal  surface  downwards, 
and  an  incision  made  along  its  upper  sui-face,  including  left 
and  right  lobes,  down  through  the  greater  part  of  its  thick- 
ness. Other  incisions  may  be  made  from  this  one  into  the 
liver  substance  at  various  depths.  The  general  appearance 
of  the  cut  surface  will  be  noted,  as  well  as  any  irregulai'ity 
of  the  capsule  or  external  surface.  The  normal  weight  of 
the  liver  is  in  the  adult  male  from  48  to  58  oz.,  and  in  the 
female  from  40  to  50  oz. 

Intestines The  large  intestine  has  been,  so  far,  sepa- 
rated from  its  attachments  (see  p.  509) ;  it  is  necessary  now 
to  remove  the  whole  gut  for  examination.  Beginning  at  the 
caput  ca3cum,  the  small  intestine  is  to  be  separated  by  cut- 
ting through  its  mesenteric  attachment.  If  the  gut  be  pulled 
pretty  firmly,  then  the  knife,  by  a  sawing  motion,  will  readily 
and  quickly  divide  the  mesentery,  which  should  be  done 
close  to  the  gut,  so  as  to  leave  no  mesentery  on  the  gut. 
When  the  duodenum  is  reached,  the  gut  is  cut  transversely. 
The  rectum  is  now  cut  through  at  the  lower  end  of  the  sig- 
moid flexure,  and  the  whole  gut  removed  and  placed  in  a 
basin  of  water.  The  gut  scissors  are  used  to  open  the  intes- 
tine. The  longer  blade  is  introduced  at  the  upper  end,  and 
the  intestine  is  pulled  against  the  commissure  of  the  blades, 
care  being  taken  that  it  is  the  mesenteric  border  which  is 
divided.  It  is  seldom  necessary  to  make  frequent  cuts  with 
the  scissors,  the  mere  projection  of  the  tissue  against  the  fork 
being  usually  sufficient.  When  the  colon  is  reached  it  is 
then   necessary  to   cut  with  the  scissors,  as  the   coats  are 


512  POST-MORTEM    EXAMINATIONS. 

thicker,  and  there  is  no  specially  weak  mesenteric  border. 
When  the  whole  length  has  been  divided,  the  suiface  of  the 
mucous  membrane  will  be  examined  from  above  downwards, 
being  passed  under  a  stream  of  water  so  as  to  remove  ad- 
hering mucus.  The  state  of  the  vessels,  the  color  and  the 
condition  of  Peyer's  patches,  and  the  solitary  glands,  will 
be  noted,  as  well  as  the  existence  of  any  pathological  con- 
dition. 

Pelvis The   organs  of  the   pelvis  still  remain.     The 

bladder  may  be  examined  by  dragging  its  anterior  wall  for- 
wards, and  making  an  incision  in  the  middle  line.  The 
finger  may  be  introduced  into  this  incision,  and  the  bladder 
pulled  forwards,  so  as  to  expose  the  mucous  membrane. 

Taking  hold  with  the  left  hand  of  the  rectum  behind,  and 
the  bladder  in  front,  the  whole  contents  of  the  pelvis  may  be 
scooped  out  with  the  knife.  The  rectum  is  now  to  be  cut 
open  with  the  gut  scissors.  In  the  case  of  the  female,  the 
probe-pointed  scissors  will  be  used  to  divide  the  vagina,  and 
then  the  uterus.  For  this  latter,  the  probe-pointed  blade  is 
passed  into  the  cavity,  and  the  incision  carried  along  the 
lateral  border,  and  then  along  the  fundus,  so  as  to  expose 
the  entire  cavity  of  the  uterus.  The  Fallopian  tubes,  ova- 
ries, and  ligaments  will  receive  attention,  and  be  incised  if 
necessary.  In  the  case  of  the  male,  the  scrotum  will  be 
opened  and  the  testicles  examined,  if  thought  necessary. 

The  viscera  being  removed,  the  aorta  and  its  branches,  as 
well  as  the  venous  stems,  may  be  exposed  and  examined. 
Incisions  will  be  made  longitudinally  into  these  vessels  as 
required. 

Head The  examination  of  the  head  should  be  done  at 

the  very  first  if  anything  specially  directs  attention  to  the 
state  of  the  brain  ;  otherwise  it  may  be  done  after  the  thorax 
and  abdomen.  A  block  is  placed  under  the  head,  so  as  to 
support  it  as  nearly  as  possible  with  the  crown  upwards. 
The  soft  parts  are  divided  by  an  incision  carried  straight 
across  the  vertex  from  behind  the  one  ear  to  behind  the 
other.  This  incision  should  penetrate  right  down  to  the 
bone  throughout.  The  entire  soft  parts  are  then  reflected 
from  the  surface  of  the  cranium  by  means  of  the  chisel,  the 
original  incision  having  divided  the  scalp  into  two  flaps.  The 
bone  is  thus  left  bare,  except  at  the  sides,  where  the  temporal 
muscles  and  the  temporal  fascia  remain.  These  are  removed 
by  the  aid  of  the  knife,  and  a  saw  cut  is  carried  round  the 
calvarium  on  either  side  from  a  little  below  the  supra-orbital 


HEAD.  513 

ridge  to  an  inch  below  the  occipital  protuberance.  This  cut 
should  not  penetrate  through  the  entire  thickness  of  the  cal- 
varium,  but  only  the  external  table.  In  sawing,  the  left 
hand,  which  is  used  to  steady  the  head,  should  be  covered 
with  a  towel,  so  as  to  protect  it  if  the  saw  slips. 

To  complete  the  separation,  the  chisel  is  inserted  into  the 
saw  cut,  and  the  internal  table  cracked  through  by  a  few 
smart  taps  with  the  mallet.  Tlie  calvarium  can  then  be 
forced  off  with  the  chisel.  In  cases  of  suspected  fracture  of 
the  skull,  it  is  well  to  saw  tlirough  both  tables,  even  at  tlie 
risk  of  injuring  the  brain  and  its  membranes  ;  otherwise,  the 
use  of  the  chisel  may  extend  an  existing  fracture,  or  even 
cause  one.  The  surface  of  the  dura  mater  is  then  to  be  exam- 
ined, and  the  longitudinal  sinus  laid  open  by  an  incision  in  the 
middle  line.  The  dura  mater  is  now  to  be  divided  by  one  inci- 
sion at  the  level  of  the  saw  cut  all  round,  and  by  another  divid- 
ing the  tentorium  between  the  hemispheres  in  front.  The  dura 
mater  will  be  reflected  from  before  backwards — the  veins 
which  enter  the  longitudinal  sinus  from  the  surface  of  the 
brain  being  cut  through  as  progress  is  made.  The  pia  mater 
of  the  convexity  is  now  exposed,  and  its  condition,  as  well 
as  that  of  its  vessels,  observed.  To  remove  the  brain,  the 
hemispheres  are  sup|:orted  in  the  left  hand,  and  the  fingers 
of  the  riglit  hand  are  insinuated  in  front  of  and  under  the 
frontal  convolutions,  lifting  up  with  them  the  olfactory  nerves. 
The  other  cerebral  nerves  are  then  cut  tlirougli  with  a  sharp 
knife  at  their  points  of  exit  from  the  skull,  beginning  with 
the  optic.  The  tentorium  cerebelli  is  divided  along  the  pos- 
terior border  of  the  petrous  portion  of  the  temporal  bone, 
and  then  the  knife  being  inserted  into  the  foramen  magnum, 
the  medulla  oblongata  and  the  two  vertebral  arteries  are 
divided  as  far  down  as  possible.  During  all  this  operation, 
the  brain  is  supported  in  the  left  hand,  and,  the  principal 
connections  being  now  divided,  the  right  hand  may  be  used 
to  take  hold  of  the  base,  and  assist  in  gently  raising  the 
brain.  The  sinuses  of  the  dura  mater  may  now  be  opened 
in  the  base  of  the  skull.  If  a  fracture  is  to  be  looked  for, 
the  dura  mater  must  be  removed,  and  this  is  done  by  catching 
the  edge  where  it  has  been  cut,  in  the  hand  armed  with  a 
towel,  and  violently  teai'ing  it  from  the  base.  The  orbit  may 
be  opened  by  removing  its  roof  with  the  chisel  and  mallet,  if 
it  is  thought  necessary. 

In  the  examination  of  the  brain  itself,  the  base  should  first 
receive  attention.     The  arteries  at  the  base  should  be  cai"e- 


514  POST-MORTEM    EXAMINATIONS. 

fully  examined  and  partially  traced  into  the  fissure  of  Sylvius 
and  the  anterior  longitudinal  fissure,  and  on  the  sui*face  of 
the  cerebellum.  The  brain  being  now  laid  on  its  base,  an 
incision  is  first  to  be  made  so  as  to  open  the  lateral  ventricle 
on  the  left  side.  For  this  purpose  the  hemispheres  are  sepa- 
rated, and  a  cut  is  made  in  a  direction  downwards  and  out- 
wards, beginning  at  the  outer  border  of  the  corpus  callosum. 
The  left  hemisphere  is  so  held  in  the  left  hand  that,  Avhen 
the  incision  reaches  the  ventricle,  the  latter  will  gape  and 
expose  its  cavity,  which  may  then  be  more  fully  laid  open. 
The  lateral  ventricle  being  fully  exposed,  its  dimensions  are 
noted,  and  any  excess  of  fluid  which  may  be  present.  It  is 
now  proper  to  explore  and  examine  the  hemisphere,  which  is 
done  by  a  series  of  parallel  cuts,  which  penetrate  from  the 
interior  of  the  vetricle  through  the  white  siibstance  outwards 
to  the  gray  matter  of  the  convolutions.  The  first  of  these 
incisions  is  almost  a  continuation  of  the  cut  which  opened 
the  ventricle,  and  is  placed  just  outside  the  corpus  striatum, 
which  lies  on  the  floor  of  the  ventricle.  The  left  hemisphere 
being  thus  explored,  the  brain  is  now  wheeled  round,  and  the 
right  lateral  ventricle  and  hemisphere  are  similarly  dealt 
witli.  The  brain  being  then  brought  back  to  its  former 
position,  the  fornix  and  corpus  callosum  are  divided  anteriorly 
by  an  incision  from  the  foramen  of  Monro  outwards.  These 
structures  with  the  choroid  plexus,  and  the  pineal  body,  are 
observed,  lifted  backwards,  and  turned  aside.  If  now  the 
cerebellum  be  supported  in  the  left  hand,  and  an  incision 
made  through  it  in  the  middle  line,  the  fourth  ventricle  will 
be  opened.  It  is  easy  now  to  take  a  survey  of  the  condition 
of  the  surface  of  the  corpus  striatum,  optic  thalamus,  corpora 
quadrigemina,  and  floor  of  the  fourth  ventricle.  While  the 
cerebellum  is  in  the  hand,  it  may  be  incised  by  a  series  of 
cuts  lying  in  the  direction  of  the  stem  of  the  arbor  vitaj,  and 
extending  through  the  substance  of  the  cerebellum. 

The  great  ganglia  in  the  floor  of  the  lateral  ventricles 
have  to  be  more  fully  examined.  In  order  to  this  the  left 
hand  is  introduced  below  the  brain,  so  as  to  support  these 
ganglia,  and  incisions  are  in  succession  made  transversely 
th]-ough  the  corpus  striatum  and  optic  thalamus  from  before 
backwards,  so  as  to  divide  them  into  a  number  of  laminte, 
first  on  the  one  side  and  then  on  the  other.  The  crura, 
cerebri,  corpora  quadrigemina,  jions  Varolii,  and  medulla 
oblongata  may  also  be  divided  by  transverse  incisions,  so  as 
to  expose  their  tissue. 


SPINE.  515 

In  this  way  the  brain  is  examined,  but  it  is  not  divided 
into  little  pieces.  It  is  like  a  book  whose  binding  is  formed 
by  the  pia  mater  of  the  surfaee,  and  the  locality  of  any  dis- 
covered lesion  can  be  readily  determined. 

In  some  cases  it  is  important  to  examine  the  organ  of 
hearing.  To  do  this  two  coverging  cuts  are  made  with  the 
saw,  so  as  to  include  a  part  of  the  lateral  wall  of  the  skull 
and  the  petrous  bone.  If  one  of  these  cuts  is  just  in  front 
of  the  external  auditory  meatus,  the  membrana  tympani  will 
be  easily  reached  afterwards.  The  tympanic  cavity  may  be 
exposed  by  breaking  through  the  thin  plate  of  bone  which 
forms  its  roof.  The  rest  of  the  internal  ear  may  be  examined 
by  means  of  the  chisel  or  bone  forceps,  or  saw.  The  mastoid 
cells  maybe  exposed  by  sawing  through  the  mastoid  process. 

Spine If  it  be  desirable  to  examine  the  spinal  cord, 

then  the  vertebral  canal  should  be  opened  before  any  other 
part  of  tlie  body.  An  incision  is  made  in  the  middle  line 
behind  from  the  occiput  to  the  sacrum.  The  skin  and  mus- 
cles are  reflected  from  the  vertebra?,  the  arches  of  which 
should  be  well  displayed.  A  block  is  placed  under  the  body 
so  as  to  make  the  vertebral  column  form  a  convexity  pos- 
teriorly, and  this  block  may  be  shifted  upwards  or  down- 
wards, according  to  circumstances.  The  arches  of  the 
vertebrae  are  sawn  through  a  little  to  the  inside  of  the  articu- 
lations, or  after  sawing  them  partially  the  division  is  com- 
pleted with  the  chisel  or  bone  forceps.  The  arches  being 
removed,  the  posterior  aspect  of  the  dura  mater  is  exposed 
and  its  condition  observed.  The  dura  mater  is  then  divided 
longitudinally  along  its  posterior  surface  by  means  of  the 
probe-pointed  scissors,  and  the  condition  of  the  posterior  sur- 
face of  the  cord  and  the  soft  membranes  observed.  The 
spinal  nerves  are  then  to  be  divided  outside  the  dura  mater 
as  near  as  possible  to  their  exits  from  the  spinal  canal,  and 
the  cord  then  removed,  beginning  with  the  cauda  equina.  In 
removing  the  cord  it  is  well  to  take  hold  of  the  dura  mater 
rather  than  the  cord,  which  will  otherwise  get  torn.  The 
medulla  oblongata  will  be  cut  transversely,  and  the  cord  thus 
removed  from  the  body.  The  anterior  aspect  of  the  dui-a 
mater  is  now  to  be  divided  longitudinally,  as  was  the  pos- 
terior. Then  the  cord  itself  is  examined  by  a  series  of  trans- 
verse incisions,  which  ought  to  divide  the  cord  completely, 
the  separate  pieces  being  held  together  by  the  spinal  nerves 
and  dui-a  mater. 

It  is  not  necessary  to  give  any  special  directions  for  the 


516  POST-MORTEM    EXAMINATIONS. 

examination  of  the  limbs.  Incisions  will  be  made  so  as  to 
expose  bones,  joints,  muscles,  nerves,  bloodvessels,  &c.,  as 
they  may  be  required. 

ExAMiXATOXs    IX   PRIVATE    HousES In    addition   to 

what  has  been  said,  it  may  be  added  that,  while  post-mor- 
tem examinations  are  most  conveniently  performed  in  rooms 
specially  arranged  for  the  purpose,  yet  it  is  often  necessaiy 
to  do  them  in  pri^•ate  houses.  In  such  cases  the  operator 
should,  before  beginning,  see  that  everything  likely  to  be  re- 
quired is  present  in  the  room.  It  is  important  to  have  a 
sufficient  supply  of  water  and  vai'ious  vessels.  There  should 
be  two  or  three  basins,  a  pail  into  which  any  blood  or  bloody 
fluid  can  be  poured,  and  one  or  two  jugs  or  ewers  full  of 
water.  Several  towels  should  be  supplied,  and  some  old 
cotton  cloth  which  can  be  used  for  cleansing  or  for  [M^otect- 
ing  the  carpet  and  articles  of  furniture  from  being  soiled.  A 
sponge  is  also  very  useful. 

Structures  removed  for  detailed  Examination 

In  some  cases  it  may  be  advisable  to  remove  portions  of  or- 
gans for  more  detailed  examination  afterwards,  or  in  order 
to  submit  them  to  a  more  skilled  observer.  When  possible 
such  structures  should  first  be  examined  in  as  fresh  a  state 
as  possible,  and  if  the  examination  cannot  be  done  on  the 
spot,  the  structure  should  be  carefully  placed  in  gutta-percha 
tissue  or  other  waterproof,  and  so  packed  as  to  prevent  eva- 
poration and  avoid  pi-essure.  If  it  be  desired  to  preserve 
parts  for  minute  microscopic  investigation,  they  may  be 
hardened  in  alcohol  or  solutions  of  chromic  acid  or  the 
chromates.  In  any  case,  but  especially  when  chromic  acid 
is  the  fluid  used,  the  structure  should  be  cut  into  small 
pieces,  and  the  fluid  should  be  so  abundant  that  no  two 
pieces  can  lie  in  contact.  This  is  very  specially  to  be  ob- 
served in  the  case  of  the  brain  and  spinal  cord.  The  pieces 
in  this  case  should  not  be  larger  than  the  terminal  joint  of 
the  finger,  and  it  is  well  to  leave  them  for  twentj^-four  hours 
in  alcohol  before  placing  them  in  solution  of  chromic  acid. 
When  it  is  proposed  to  submit  these  parts  to  more  skilled 
investigation  they  should  be  forwarded  at  once,  and  in  the 
alcohol,  the  further  process  of  hardening  being  left  to  the 
individual  investioator. 


INDEX. 


AN  =  Anode,  218 
A.S.  =  Auricular-systolic,  465 

Abdomen,  disease  of  organs  there 
predisposing  to  melancholic  in- 
sanity, 236;  distension  with  wind, 
315;  pains  and  tenderness,  317; 
tumor  from  pregnancy,  413;  pains 
in,  316;  dropsy  of,  339;  percus- 
sion dulness  in  ascites  {Fig.  40), 
339  ;  duhiess  in  ovarian  dropsy, 
(Fig.  41),  340  ;  cystic  accumula- 
tions in,  341  ;  colloid,  in  abdom- 
inal cavity,  341  ;  examination  of, 
for  tumors  after  tapping,  346  ; 
physical  examination  of  (chapter 
xvi.),  429  ;  works  of  reference  on 
examination    of   abdomen,    429; 

■  physical  examination,  478 ;  re- 
gions (Fig.  82),  47S  ;  contents  of 
regions,  479  ;  viscera  in  situ, 
(Fig.  83),  479;  inspection,  479; 
distension  and  retraction,  480 ; 
pigmentation,  480  ;  white  lines, 
480  ;  dropsy,  481  ;  movement  with 
respiration,  481  ;  pulsation  visi- 
ble, 481 ;  palpation,  482  ;  percus- 
sion, 4b3  ;  mensuration,  483  ;  aus- 
cultation, 483  ;  auscultatory-per- 
cussion,  484  ;  abdominal  organs, 
484;  liver,  484;  spleen,  490; 
kidneys,  492;  pancreas,  494; 
stomach,  494;  intestines,  496; 
tympanites,  496;  ascites,  497; 
ovarian  tumors,  499  ;  various  tu- 
mors, 499  ;  localities  of  tumors, 
601 

Abducens  oculi,  162 

Abscess,  of  br.iin,  due  to  ear  dis- 
ease, 145;  causing  paralysis,  181  ; 
pelvic,  426 ;  abscess,  of  lung, 
liver,  &c.,  see  Lung,  Liver,  &o. 

Acarus  seabiei  (Fig.   18),  98 

44 


Accommodation  of  eye,  range  of, 
139;  defects  with  age,  155;  in 
defects,  155  ;  strain  on,  155  ;  pa- 
ralyzed, 155;   asthenopia,  155 

Achorion  Schonleinii  (Fig.  20),  104 

Acid  fermentation  of  urine,  353 

Acidity  in  stomach,  315  ;  of  urine, 
353 

Acne,  96,  97,  102 

Addison's  disease,  35,  116 

Adolescence,  diseases  of,  26 

Jilgophony,  448 

Ageing,  26,  41 

Ageustia  or  ageusia,  148 

Ague,  tertian,  temperature  in,  75  ; 
as  cause  of  neuralgia,  184;  of 
splenic  tumor,  492 

Air-bubbles  in  urine  (Fig.  56  d), 
381 

Albinism,  117 

Albuminuria,  convulsions  due  to, 
190  ;  absence  of,  occasionally  in 
renal  dropsy,  337;  tests  for  albu- 
men, 361  ;  heat  test,  361;  nitric 
acid  test,  362  ;  estimation  of  quan- 
tity of  albumen,  363;  significance 
of  albuminuria,  364;  due  to  pus, 
blood,  &a.,  364,  367 ;  in  acute 
febrile  disease,  364  ;  after  scarla- 
tina, 365;  in  pregnancy  and  pu- 
erperal state,  365  ;  in  chronic 
chest  disease,  365  ;  in  dropsies, 
365  ;  in  renal  disease,  38f^ ;  in 
nervous  diseases,  366  ;  in  chronic 
constitutional  diseases,  366  ;  after 
blisters,  366  ;  presence  and  ab- 
sence of  tube-casts,  376 

Alcohol,  use  of,  importance  of,  in 
case  taking,  62  ;  influence  on  pu- 
pil, 136  ;  cause  of  insanity,  228  ; 
alcoholic  insanity,  various  forms, 
232 


518 


INDEX. 


Algide  stnge  of  cholern,  37 

Alk:ilinity  of  urine.  353  :  from  de- 
composition, 353;  from  medi- 
cines, 354;  volatile  and  fixed  al- 
kali in  urine,  354 

Alopecia,  97,  103 

Alphos.  95 

Alternate  squint,  130  :  alternate 
paralysis,  166 

Amriurosis,  see  Blindness,  157 

Amblyopia,  157 

Amenorrhcea  and  insanity,  229  ; 
primitive,  401  :   secondary.  403 

Ammonia,  in  breath,  test  for,  196 

Amnesia  or  Amnesic  asphasia,  176 

Amphoric  breathing,  '139 ;  pheno- 
mena, 446  ;  echo.  447 

AniEmia,  34  ;  with  bronzing.  35 ; 
venous  murmur  in,  36  :  causes  of, 
36;  a  cause  of  vertigo,  201;  blood 
in,  16,  2S2,  284:  dropsy'  from, 
377  ;  cardaic  murmurs  from,  472 

Ansesthesia,  tests  of,  150,  151  ; 
range  of,  162;  in  diphtheria, 
hysteria,  and  ataxy,  152  :  hemi- 
anesthesia, 152  ;  Tvith  trophic 
changes,  152;  and  neuralgic,  152; 
feeling  of  ansesthesia,  160:  and 
paralysis,  168  :  distribution  of, 
168  ;  hemi  ansesthesia,  168  :  in  re- 
gions of  special  nerves,  168:  ab- 
sence of.  in  lend  and  infantile 
paralysis,  163>  affecting  writing, 
177  :  electricity  in,  218  :  hysteri- 
cal, test  by  electricity,  219 

Analgesia,  153 

Anderson  (MCall)  on  classification 
of  skin  disease,  97 

Ana.'arca,  337 

Aneurism,  in  retina,  142  ;  treat- 
ment by  galvano-puncture,  210; 
causing  laryngeal  affection,  164, 
265.  271,  299  ;"a  cause  of  haemop- 
tysis, 276;  duhiess  of,  and  pulsa- 
tion in  chest,  458,  475  ;  murmurs 
due  to.  472  ;  thoracic  aneurism, 
475  ;  percussion  signs,  476  ;  aus- 
cultation. 476;  signs  at  back  of 
thorax,  477  ;  conditions  simulat- 
ing, 477 

Angina  pectoris,  264  ;  "  angina  sine 
dolore,"  266 

Anorexia,  304 

Anosmia,  147 

Anthrax,  bacterium  in  blood,  283 

Aorta,  valvular  disease  of,  pulse 
in,  81  :  tracing,  84  ;  aneurism  of, 
tracing  of  pulse  on  two  sides,  85  ; 


throbbing  of  abdominal  aorta, 
263  ;  dulness  and  pul.-ation  from 
thoracic  aneurism,  458  ;  tremor 
in  aneurism,  460 ;  alteration  of 
heart's  sounds  in  aortic  disease, 
463  ;  aortic  murmurs,  area  of, 
471 ;  murmurs  due  to  aneurisms 
of,  473 

Aortic  cartilage,  463,  471 

Apex-beat  of  heart,  normal,  449,^ 
451 ;  obscured,  453  ;  efi'ect  of  re- 
spiration on,  453  :  exaggerated, 
454;  displaced.  454;  distinction 
from  heave  of  right  ventricle,  455 

Aphasia,  175;  varieties  of,  176; 
causes  of,  177  ;  with,  and  without 
hemiplegia,  177  ;  from  embolism, 
ISO 

Aphemia.  175 

Aphouia,  see  Voice,  loss  of 

Aphtha,  94;  on  tongue,  305,  307 

Apjohn's  method  of  urea  analysis 
(Fig.  63),  393 

Apnoea,  apparent,  266:  see  As- 
phyxia, and  al.=o  various  sections 
under  Dyspnoea 

Apoplexy,  see  Sudden  paralysis, 
194  :   threatenings  of,  200.  204 

Appetite,  impaired,  inordinate,  per- 
verted, 304 

Arciis  senilis,  26,  123 

Area  of  cardiac  murmurs,  464,  473 

Areola  of  nipple  in  pregnancy,  413  ; 
umbilical,  480 

Aretaeus  on  phthisical  physiogno- 
my, 38 

Arm,  pain  in  left  arm,  264 

Arsenic,  itching  from,  100  ;  rash 
from,  102 

Arterial  degeneration,  groups  of 
diseases  allied  to,  65 ;  rigidity  of 
arteries,  80  ;  tracing  of  pulse  in, 
84 

Arterial-diastolic  murmurs,  474 

Artery,  survey  of  state  of,  SO  ;  rigi- 
dity, twisting,  <S:c.,  80;  increased 
arterial  tension  (tracing),  85; 
audible  pulsation  of,  159 

Articulation,  see  Speech 

Aryteno-epiglottidean  folds  in  la- 
rynx, 296 

Ascaris  lumbricoides  vomited,  316  ; 
in  motions,  322 

Ascites,  339,  497  ;  percussion  dul- 
ness in  Fig.  40,  340  ;  fluctuation 
in,  340  ;  distinction  from  ovarian 
'  dropsy,  341  ;  causes  of  ascites, 
342  ;  peritonitis,  343  ;   tabes  me- 


I N  r>  E  X . 


519 


senteric!!,  343;  portal  obstruc- 
tion, cirrhosis,  thrombosis,  can- 
cer. <tc.,  343,  345  ;  examination 
of  fluids,  346 

Asphyxia,  galvanism  for,  221  ;  see 
also  various  sections  under  Dys- 
pnrea 

Asthenopia,  155 

Asthma,  cause  of  insanity,  235  ; 
cardiac,  260 ;  see  also  various 
sections  on  Dyspnoea,  256 

Astigmatism,  138,  139  ;  cause  of 
strain  on  eyes,  155 

Asylum  treatment  in  insanity,  ques- 
tion of,  253 

Ataxy,  locomotor,  gait  in,  47;  an- 
aesthesia in,  152;  sense  of  tem- 
perature, 153  ;  sense  of  weight, 
153;  diplopia  in,  154;  walking 
in,  171,  172,  173,  174;  ataxic 
aphasia,  174:  influence  of  sexual 
excesses  in  causing  ataxy,  182  ; 
distinction  from  general  paraly- 
sis, 254 

Atheroma  of  cerebral  vessels  as  a 
cause  of  hemiplegia,  181 

Athetosis  (Hammond's),  171 

Atrophy,  of  tissues,  with  hypertro- 
phy, 31;  phthisical,  33;  of  skin, 
97;  of  optic  nerve,  141,  142;  of 
parts  with  anaesthesia,  152  ;  of 
muscles,  182,  183 

Atropine,  rash  from,  102;  influ- 
ence on  pupil,  135,   136 

Auditory  nerve,  testing  of,  163, 
(144  and  158) 

Aura  epileptica,  187 

Aural  speculum,  examination,  &o., 
144 

Auricle,  visible  pulsation  in,  455 

Auricular-systolic  murmur  (Fig. 
75),  465 

Au.-:cultation  of  pregnant  uterus, 
414;  pulmonary,  440;  breath 
sounds,  natural  and  abnormal, 
442 ;  rales,  445 ;  metallic  and 
amphoric  signs,  446  ;  vocal  reso- 
nance, 447;  of  heart's  sounds, 
4&\  ,et  seq. ;  murmurs,  464,  et  seq. ; 
of  aneurisms,  476  ;  of  abJomen, 
483 

Auscultatory-percussion,  484 

Auto-laryngosciipy.  Foulis's  meth- 
od, 295  ;   Johnson's,  296 

Automatic  actions  in  hemiplegia, 
170;   in  epilep-!y,  188,  234 

Autnphagy,  28 

Autophonic  resonance,  448 


Autopsy,  see  Post-mortem  examin- 
ation, chap.  xvii. 

Axilla,  how  temperature  taken  in, 
69;  as  compared  with  vagina  in 
collapse,  77  ♦ 

BACILLUS  anthracis,  285;  ba- 
cillus subtilis,  285 

Backache  in  fever,  86 :  various 
causes  of,  205  ;  see  Menstrua- 
tion, Dysinenorrhcea,  ka.,  and 
other  parts  of  chapter  xv 

Bacteria  in  blood,  284;  in  urine, 
379 

Balancing  of  body,  unsteadiness 
in,  171;  testing  of,  172;  rela- 
tionship of  sight  to  balancing, 
173 

Baldness,  103 

Balfour,  Dr.  Geo  ,  on  so-called 
htewic  murmurs,  471 

Ballottement,  413 

Barking  cough,  271 

"Barrel-shaped"  chest,  431 

Basedow's  disease,  see  Exopthalmic 
goitre 

Bateman,  Willan  and,  93 

Batteries,  various  forms,  207;  bat- 
tery current,  208 

"Bearing-down"  pains,  408 

Becker-Muirhead's  elements,  207 

Beer,  use  of,  case  taking,  62 

Belladonna,  rash,  1U2;  influence 
on  pupil,  135,  136 

Bell's  paralysis,  see  Facial  nerve 
(162) 

Bell  sound  in  auscultation,  447 

Bile,  vomited,  313;  in  motions, 
320  ;  inspi  sated,  see  Gall-gtones  ; 
bile  in  urine,  3S9  ;  bile-pigment, 
388  ;  biliary  acids,  389 

Bismuth,  cause  of  bad  smell,  158  ; 
test  for  sugar,  360 

Black  spit,  273  ;  black  vomit,  313; 
black  stools,  320  ;  black  urine, 
355 

Bladder,  paralysis  of,  178;  reflex 
paralysis  from  disease  of,  180  ; 
electricity  in  paralysis  of,  221; 
distension  of  simulating  ascites, 
<tc.,  340;  epithelium  from,  377, 
378;  distension  of,  causing  tumor, 
499 

Blebs,  94 

Bleeding  from  nose,  ka.,  with 
whooping  cough,  270  ;  from  va- 
rious pirts,  see  section  on  Hem- 
orrhages, 279 


520 


INDEX. 


Blepharnspnsm,  138 
Blindness,  157 
Blisters,  94 

Blood,  in  ansemia,  36  ;  in  cholera, 
37;  in  leukseraiii,  120;  in  f!;out, 
test  for  uric  scid,  125 ;  blood 
crystals,  274;  blood  in  spit,  274, 
277 ;  vomiting  of,  from  lungs, 
275 ;  various  forms  of,  275 ; 
losses  of,  279;  examination  of 
blood,  981  ;  bufiFycont  of  blood, 
281  ;  in  leukaamia  and  anaamia, 
method  of  examination  by  micro- 
scope, 282;  by  hsemochromometre, 
285;  relative  estimation  of  white 
corpuscles,  282  ;  counting  abso- 
lute number,  282;  Mnlassez's 
method,  283;  Jlayem  and  NacVet's 
method,  283 ;  Govvers's  method, 
284 ;  estimation  of  total  white 
and  red  corpuscles,  283,  284; 
white  corpuscles,  variation  in 
size,  284  ;  changes  in  shape  of 
red  corpuscles,  284;  fragments  of 
protoplasm  in  blood,  285;  small 
colored  cells  in  blood  and  in- 
creased size  of  red  corpuscles  in 
ana3mia,  285;  pernicious  anae- 
mia, 284 ;  living  organisms  in 
blood,  285;  bacillus  anthracis, 
spirilla  of  relapsing  fever,  filaria 
sanguinis,  285 ;  vomiting  of, 
from  stomach,  312;  from  bowels, 
320  ;  passed  in  urine,  367  ;  blood 
corpuscles  in  urine  (Fig.  44), 
367;  guniac  test  for  blood  in 
urine,  368;  blood-casts  (renal), 
376  ;  resemblance  of  spores  to 
blood  corpuscles,  379.  See  also 
Hemorrhages. 
Blueness  of  face  in  dyspnoea,  265 
Body-weight,  29  (see  Weight) 
Boil,  96,  97 

Bones,  aflfections  of,  in  syphilis,  122 
Bowels,  paralysis  of,  178;  obstruc- 
tion of,  simulated  by  paralysis, 
174;  electricity  in  paralysis  of, 
221  ;  disorder  of,  and  vomiting, 
310;  flatulence,  314;  state  of 
bowels,  and  pains  in  bowels,  315, 
319;  motions  from,  319;  signifi- 
ciince  of  constipation  and  diar- 
rhoea, 325  ;  physical  examination 
of  intestines,  534.  (See  also 
Tympanites,  Ascites,  &g.) 
Brain  affected  from  ear,  145  ;  signs 
of  disense  from  ophthalmoscope, 
142;    galvanizing,   220;    abscess 


and  tumor  of,  causing  paralysis, 
181  ;  affections  causing  sighing 
respiration,  266.  (See  also  Cra- 
nial nerves.  Hemiplegia,  Convul- 
sions, Aphasia,  Coma,  &c.) 

Breast-pang,  see  Angina  pectoris 

Breasts,  see  Mammae 

BreTth,  coldnDss,  37;  foulness  of, 
307 

Breath  sounds,  see  Respiratory 
murmur 

Breathing,  labor  in,  258 ;  altered 
rhythm  of  266  ;  sighing  or  sus- 
pirius,  266.  (See  chapter  ix. 
jiassim) 

Bright's  disease,  arterial  tension 
(tracing) ,  86  ;  lesions  of  retina, 
142;  convulsions  in,  189;  albu- 
minuria in,  366 

Bromide  of  potassium,  rash  from, 
102 

Bronchi,  foreign  bodies  in,  causing 
cough  and  simulating  phthisis, 
272  ;  dilatation  of,  from  same 
cause,  272 

Bronchial  breathing.  442,  444 

Bronchial  phthisis,  270  ;  bronchial 
glands  affected,  271 

Bronchiiil  catarrh  in  fevers,  88 

Bronchophony,  448 

Bronchorrhcea,  274 

Bronzed  skin,  36,  116 

Bruit  dedi:ible,  475 

Bruit  de  pot  tele,  440  ;  for  cardiac, 
arterial,  and  venous  bruits,  see 
Murmurs 

Broad  ligament,  inflammation  of, 
424 

Bronchi,  foreign  bodies  in,  causing 
cough  and  simulating  phthisis, 
272;  dilatati  n  of,  from  same 
cause,  272 

Bubbling  r^les,  445 

Buccinator,  paralysis  of,  161,  163 

Buchanan  (A.  B.)  on  classification 
of  skin  disease,  97 

Bulbar  paralysis,  progressive,  163 

BullEB,  94 

Bunsen"s  battery,  207.  See  Stoh- 
rer's  also 

CACHEXIA,  39;  cachexia;  and 
pyrexiae,  410;  scrofulous  or 
strumous,  40;  gout,  40;  cancer- 
ous, 41;  dropsical,  41  ;  rheumat- 
ic, 41  ;  rickety,  42  ;  syphilitic, 
43 
Caerulean  disease,  265 


INDEX. 


521 


Calabar-bean,  influence  on  pupil, 
136 

Calcareous  mnsses  in  spit,  274 

Calculi,  biliary,  see  Gall-stones  ; 
urinary  calculi,  anylysis  of,  388 

Caligraphy,  see  Writing 

Callositiis,  97 

Cancer,  cachexia  in,  41  ;  increase 
of  white  corpuscles  in  blood,  282  ; 
"  cancer  cells"  in  vomited  mat- 
ter, 313;  cancer  of  womb  ,  426 

Cantharides,  a  cause  of  bloidy  urine 
and  strangurj',  369 

Ciirbolic  iicid,  effect  on  urine,  355 

Carbonate  of  lime,  386 

Cardiac  dyspnoen,  260,  261  ;  cardiac 
asthmsi,  260.     See  Heart 

Caries  of  teeth,  329 

Ciirphologia,  46 

Carpo-pedal  spasm,  191 ;  oedema  of 
hands  and  feet,  with,  338 

Cartiiiiges.  laryngeal,  inflammation 
of,  298 

Caseine,  precipitation  of,  from 
urine  by  acetic  acid,  363 

Case- taking,  53 

Casts,  of  larynx,  trachea  and  bron- 
chi expectorated,  274  ;  of  gastric 
follicles,  314;  of  renal  tubes,  see 
Tube-casts 

Catalepsy,  191,  195 

Catamenia,  see  Menstruation 

Cataract,  156 

Catarrh,  bronchiiil,  in  fevers,  88, 
271;  post-nasal  causing  cough, 
271;  of  fauces,  288;  of  larynx; 
297;   catarrhal  jaundice,  333 

Catheter,  shiverings  from  passing, 
44 

Cauliflower  excrescence  from  ute 
rus,  427 

Cautery,  galvanic,  209 

Cavernous  respiration,  444;  pheno- 
mena, 446;   rale,  445 

Cellulitis,  pelvic,  419 

Cerebellar  disease,  staggering  in, 
48,  171 

Cerebral  nerves  (see  nerves,  136)  ; 
cerebral  prespiration,  267 

Cervix,  see  Uterus 

Chalk  stones  in  gout,  41,  126 

'■Change  of  life,'  406;  insanity 
at,  229 

Charbon,  bacterium  in  blood,  285 

Cheek,  paralysis  of,  163  ;  lividity 
of,  206  ;  induration  from  conges- 
tion, 266 

Cheesy  masses  in  spit,  274 

u 


Cheloid,  97 

Chemical  effects  of  electriei-ty,  209 
Chest,  pain  in,  255,  263,  264;  uni- 
lateral changes  in  shape,  433 ; 
movements  of,  434 ;  palpation, 
435  ;  menstruation,  436  ;  percus- 
sion, 437;  auscultation,  see  Lungs, 
Heart;  chest-rule;  440  ;  physical 
examination    of    (Chapter    xvi), 

429  ;  regions  of,  429  ;  works  of 
reference    on,    429  ;     inspection, 

430  :  shape,  430  ;  tnble  of  circum- 
ferences and  diameters,  431  ;  trac- 
ings of  healthy,  "pigeon-breast," 
rickety,  emphysematous,  and  dis- 
torted chests  (Figs.  64-68),  482, 
433 

Cheyne  Stokes  Respiration,  266 

Chicken-pox,  94,  li  9,  see  Varicella 

Childhood,  history  of  illnesses  in, 
58 

Chilliness,  in  fever,  87,  160 

Chloral,  influence  of,  on  pupils,  137 

Chlorides  in  urine,  390  ;  in  fluid 
from  hydatid  cysts   347 

Chloroform,  influence  on  pupils, 
136 

Chloroform  poisoning,  electricity 
for,  221 

Chlorosis,   35 

Choking  in  general  paralysis,  243  ; 
sound  of,  in  dyspnoen,  265 

Cholera,  collapse  in,  37;  blood  in, 
37;  liviility  in,  266;  cholera  in- 
fantum, 326 

Cholesterine  in  spit,  277  ;  obtained 
from  gall-stones,  335  ;  in  ovarian 
fluids  (Fig.  43),  347;  in  urine, 
386 

Chorda  tympani  nerve,  149,  162 

Chorea  and  pnrilysis,  171  ;  hemi- 
chorea,  171,  197;  post-hemiplegie, 
171;  and  nphasia,  177;  choreic 
twitching,  197;  fentures  of,  197; 
local  choren,   198 

Chromopsia,  157 

Chyluria,  filarial  in  bbiod,  285  ;  co- 
agulum  in  urine,  356 

Cic-itrix,  97 

Ciliary  muscle,  see  Accommodation 

Circular  insanity,  240 

Circulatory  system,  in  case-taking, 
57;  Chapter  ix.  on  disorders  of, 
255;  works  of  reference  on,  255; 
see  also  Pulse,  Chapter  iii. 

Circumvnllate  papillffi  enlarged,  306 

Cirrhosis,  see  Liver,  Lung 

Clavus,  97 
* 


622 


INDEX. 


Clayey  motions,  .320,  333 

Clicking  rale,  445 

Climncterie  period,  insnnity  at,  229 ; 
section  on,  406 

Climbing,  cause  of  dyspnoea,  2G1 

Clonic  convulsions,  187 

Coccyx,  position  of,  416 

Cockle-shaped  crusts,  96 

Coffee-grounds  vomiting,  311,  312 

Cog-wheel  respiration,  443 

Cohn  on  "  spirochsete  Obermeieri," 
285 

Coil,  importance  of,  in  batteries, 
208 

Coldness  in  collapse,  37;  feeling  of, 
160  ;  of  limbs,  160  ;  of  limbs,  gal- 
vanism for,  221 ;   of  tongue,  307 

Colic,  318;   biliary,  335 

Collapse  of  cholera,  37  ;  in  perito- 
nitis and  perforation  of  bowel, 
37  ;  collapse  temperature,  77 

Color,  spectra  with,  167;  color- 
blindness, 157 

Color  of  urine,  Vogel's  table,  354 

Comn,  in  feveis,  45;  Coma  vigil, 
46  (see  also  Unconsciousness)  ; 
causes  of  coma,  196;  complica- 
tions with  paralysis,  convulsion, 
and  fever,  196,  227;  ursemic,  195 

Comedones,  97 

Conjunctivii,  yellowness  of,  128, 
333  ;  suffusion  and  congestion  of, 
129  ;  hemorrhages  in,  280 

Communiciins  noni,  105 

Commutator  for  reversing  currents, 
214 

Compasses,  test  of  tactile  sense  by, 
151 

Complications,  effect  on  tempera- 
ture, 77 

Conidia,  104 

Consciousness  in  paralysis,  167;  in 
fits,  188;  in  hysteria,  190;  loss 
of,  in  paralysis,  194 

Constant  current,  electricity,  208 

Constipation  as  sign  of  paralysis, 
178;  various  forms  of,  316;  sig- 
nificance of,  325 

Constriction  of  body,  feeling  of, 
160;  of  chest,  263 

Contagion  in  cutaneous  eruptions, 
100 

Continuous  current  (electricity), 
208;   interruption  of,  213,  217 

Contraction  of  limbs,  170 

Convalescents,  temperature  of,  78 

Convergence  of  eyes,  strain  on, 
165 


Convulsions,  in  fevers,  88  ;  of  oculnr 
muscles,  138;  of  muscles  of  neck, 
164;  unilateral  and  hemiplegia, 
170;  nodding  convulsions,  193, 
171;  "snlanm,"  172;  unilateral 
in  aphasia,  177;  section  on  con- 
vulsive fits,  187  ;  epileptiform, 
188  ;  ionic  and  clonic,  187  ;  uni- 
lateral and  local,  187  ;  in  apo- 
plexy, 188;  in  hysteria,  188:  in 
rickets  and  laryngismus,  189, 
279  ;  in  acute  fevers,  Ac,  189  ; 
in  brain  diseases,  189;  from 
worms,  teething,  stomach  de- 
rangement, &c.,  189;  in  diarrhcea, 
189;  puerperal,  190;  in  Bright's 
disease,  190  ;  hical  or  partial, 
191;  "  Jacksonian,"  191;  carpo- 
pedal  spasms  in,  191;  convulsive 
tic,   193;   in  insanity,  233 

Cooing  sounds  in  auscultation,  445 

Copaiba,  rash  from,  102 

Copper  test  for  sugar,  357 

Cord-like  constriction  of  trunk,  160 

Cords,  vocal,  296  ;  false  cords  in 
larynx,  296 

Cornea,  opacities  of,  128;  ulcera- 
tions with  anaesthesia,  152 

Cornu.  97 

Corpulence,  32 

Corpuscles,  red  and  white,  see 
Blood 

Cotton  fibres  in  urine  (Fig.  56a), 
381 

Cough,  section  on,  268,  stomach 
cough  and  reflex  cough,  269  ;  im- 
perfect closure  of  glottis  in  some 
laryngeal  coughs,  268,  300 ;  in 
whooping  cough,  269  ;  paroxys- 
mal, 269,  27ti;  with  vomiting, 
27  0;  with  bleeding  from  nose, 
Ac,  270;  in  bronchial  phthisis, 
270  ;  in  measles  and  influenza, 
270  ;  from  irritation  or  diseases 
of  throat  and  larynx,  270;  bark- 
ing and  brassy,  271  ;  hoarse 
croupy  cough  in  croup  and  diph- 
theria, 271  ;  sometimes  hoarse  in 
thoracic  aneurism  and  pericar- 
ditis, 270,  272 ;  from  foreign 
bodies  in  larynx,  trachea,  or 
bronchi,  272  ;  absence  of,  in  cer- 
tain pulmonary  affections,  268, 
272  ,  alteration  of,  from  laryngeal 
affections,  300 

Cracked  pot  sound,  440 

Cramp,  in  limbs,  170;  writer's,  177; 
in  legs  and  limbs,   192 


INDEX. 


523 


Crnnial  nerves,  testing  of,  128,  160 
(see  Nerves)  ;  paralysis  of,  in 
pquint,  134  j  affected  in  syphilis, 
181 

Crepitus  and  crepitant  r&le,  446 

Crisis,  temperature  in,  75;  diseases 
characterized  by  sudden  crisis, 
75  ;   pseudo-crisis,  76 

Crossed  diplopia,  132  ;  crossed  para- 
lysis, l(i5 

Croup,  271  ;  false  croup,  271 

Crowing  inspiration,  186,  265.  269 

Crusting  (in  s-kin  diseases),  96  ;  in 
syphilis,  118 

Crystals  in  sputum,  277  ;  deposit  of, 
in  urine,  Bbl 

Currents,  of  various  kinds  from 
batteries,  207;  labile  currents, 
214;   descending  (electrical),  219 

Cup-shaped  crusts,  96 

Curving  of  nails,  118 

Cusco's  speculum,  422 

Cutaneous  eruptions,  91;  see  also 
Skin 

Cutis  anserina,  43,  160 

Cyanosis,  265  ;   tongue  in,  307 

Cylinders,  renal,  see  Tube-casts 

Cyrtometer,  430  ;  tracings  by,  432, 
433 

Cystine,  386 

Cysts,  97 ;  fluid  accumulations  in 
abdomen,  342;  parasitic  hydatids 
(Fig.  42),  346 

1  \  ALTONISM,  see  Color-blindness 

jj     Di.niell's  battery,  207 

Deafness,  144 ;  noises  in  the  ear 
with,  and  giddiness  with,  158 

Death,  temperature  before,  high  and 
low,  71  ;  variations  in  tempera- 
ture, 76  ;  sense  of  dying  in  angina, 
284  ;  examination  of  body,  post- 
mortem (Chapter  xvii.),  603 

Defecation,  painful,  319;  straining, 
319 ;  pain  in,  from  uterine  dis- 
order, 4(19 

Deglutition,  see  8th  and  9th  nerves, 
164;  spasms  of,  194;  affected  in 
general  paralysis,  245  ;  swallow- 
ing affected  trom  state  of  tongue, 
307 

Delirious  mania,  acute,  228 

Delirium  in  fever,  44,  87  ;  delirium, 
features  of,  19a:  and  mania,  199, 
202  ;  in  intemperance,  199  ;  with 
sleeplessness,  202 ;  diagnosis  of 
insanity,  and  delirium,  248    . 

Delirium  tremens,  199 


Delusions,  definition  of,  224 

Dementia,  from  alcohol,  "232  (see 
also  Mania,  Melancholia,  Mono- 
mania) ;  paralytic  dementia,  242, 
244  ;  section  on  various  forms, 
246;  senile,  246;  organic,  246; 
acute  or  primary,  247  :  resem- 
blance to  melancholy  with  stupor, 
247 

Dentition,  first,  326  ;  disorders  of, 
326  ;  second,  327 

Dermatitis,  97 

Desquamation,  S6  :  in  scarlatina, 
107 

Desquamation  of  epithelium  from 
tongue,  306 

Deviation,  primary  and  secondary 
in  squint,  129  ;  conjugate  or 
lateral  deviation  of  eyes,  138  ;  of 
head,  138  :  of  tongue,  165 

Dexio-cardia,  454 

Diabetes  insipidus,  352 

Diabetes  mellitus  (see  Sugar  in 
urine),  356 

Diasnusis,  physical  (Chapter  xvi.), 
429 

Diaphragm  in  respiration,  435 

Diarrhoea,  316  ;  significance  of,  325 

Diathesis,  36  ;  rheumatic,  41  ;  in- 
sane, see  Temperament,  228;  he- 
morrhagic,  280 

Dicrutism  in  pulse,  81,  84 

Digestive  system,  in  case  taking, 
67  ;  di.^turbance  of,  in  fever,  86; 
chapter  xi.  on  disorders  of,  303  ; 
works  of  reference  on,  303;  ap- 
petite, 304;  thirst,  304;  tongue, 
305;  vomiting,  308;  flatulence 
and  hiccup,  314;  state  of  bowels 
and  abdciminal  ])ain,  316  ;  worms, 
322  ;  appearance  of  motions,  322  ; 
significance  of  constipation  and 
diarrhoea,  325  ;  teeth  and  gums, 
326 ; jaundice  and  dropsy  (Chap- 
ter xii.),  332 

Diphtheria,  glands  in,  121  ;  occa- 
sional rash  in,  105;  laryngeal, 
causing  cough.  271  :  affection  of 
throat,  289;  distinction  from  mu- 
guet,  290 

Diplopia,  130,  131  ;  relation  of  im- 
ages in,  131;  "direct"'  or  "ho- 
monymous" and  "  crossed,"' 132; 
variations  of  diplopia  with  para- 
lysis of  special  muscles  (table), 
133,  134;  diplopia  monocularis, 
artificial  pupil,  &c.,  154;  binocu- 
laris,  154 


524 


INDEX. 


Dipsomania,  233 

Direct  murmurs,  465 

Di.-k.  optic,  choked  disk,  itc,  see 
Optic  nerve 

Discoloration  of  skin, various  causes, 
115,  116 

Diuresis,  see  Urine,  quantity  of 

Diurnal  range  of  temperature,  71 

Double  vision,  see  Diplopia 

Douglas's  pouch,  inflammation  of, 
417,  419,  421,  426 

"Down-bearing"'  pain,  408 

Dreams,  disturbed,  203:  of  terror, 
203  :  in  mania,  227 

Dropsy,  cachexia  of,  41  ;  chapter 
xii.  on  dropsy,  332,  337;  works 
of  reference  on,  332  ;  concurrence 
of  jaundice  and  dropsy,  334; 
anasarca  and  cedema,  337;  "pit- 
ting'" in,  337  ;  renal  dropsy,  oc- 
casionally without  albuminuria, 
337  ;  anaemic  drop>y,  337  ;  cedema 
of  feet,  337  :  oedema  of  upper 
part  of  body,  338  ;  of  hands  and 
feet  in  children,  338;  abdominal 
dropsy,  339;  of  abdominal  pari- 
etes,  339  ;  of  peritoneum,  339  ■ 
ovarian  dropsy  and  encysted 
fluids,  341  ;  causes  of  ascites, 
342 ;  peritonitis  with  effusion, 
342  :  tabes  mesenterica,  343  ;  por- 
tal obstruction,  343;  from  cir- 
rhosis, 343  ;  thrombosis  of  portal 
vein,  344;  in  cancer,  345;  from 
enlarged  spleen,  345  ;  examina- 
tion of  dropsical  fluids,  346  ;  al- 
buminuria in,  365 

Drunkenness,  and  insanity,  232  ; 
mistaken  lor  insanity,  250 

Drysdale's  ovarian  cells,  348 

Duchenne,  emporte-pieee  histolo- 
gique.  169 

Duck  bill  speculum,  422 

Dulness,  see  Percussion 

Dumbness,  see  Speech 

Dumb-bell  crystals,  3S2,  385 

Duskiness  of  face,  265 

Dynamometer,  169 

Dysmenorrhoea,  405 

Dysphagia,  see  Deglutition,  difii- 
culty  in 

Dyspnoea,  section  on,  255  ;  rapidity 
of  breathing,  256  ;  laborious 
breathing,  258  ;  sundenness  of 
dyspnoea,  259;  mechanical  causes 
of  dyspnoea,  259  ;  cardiac  dysp- 
noea, 260;  orihopnoea,  260;  with 
hurrying,  climbing,    and    excite- 


ment, 261  ;  cause  of  thoracic 
pain,  263  ;  with  palpitation,  263; 
noise  emitted  in,  265  ;  lividity 
in,  265  ;  altered  rhythm  of  breath- 
ing, 266 ;  nervous,  hj^sterical, 
and  renal,  266 ;  in  pregnancy, 
267 

EAR,  bead-like  nodule  in  gout, 
126;  works  of  reference  on 
ear,  128;  examination  of  ear, 
144;  discharges  from,  144;  sup- 
puration from,  as  cause  of  cere- 
bral abscess,  and  meningitis,  and 
P3'femia,  145;  noises  in,  158  (see 
also  Tinnitus  aurium)  ;  vertigo, 
100;  galvanism  for  affections  of 
ear,  221  ;  hjeinatoma  auris  in 
general  paralysis,  243 

Ecchymosis,  115;   in  tongue,  307 

Ecchinococci  (Fig.  42),  346 

Echo,  amphoric,  447 ;  of  heart's 
sounds,  464,  474 

Eclampsia,  see'  Epileptiform  con- 
vulsiocs 

Eclampsia  Epileptiform  nutans,  172, 
194 

Ecthyma,  95,  97 

Eczema,  94,  97 

Eichorst,  on  small  colored  cells  in 
blood  in  pernicious  anaemia,  284 

Eighth  nerve,  164 

Electricity  and  electrical  instru- 
ments, chapter  vii.  p.  207  ;  works 
of  reference  on,  207  ;  methods  of 
application,  2119;  thermic  and 
chemical  effects,  209 ;  electroly- 
sis, 209  ;  action  on  muscles,  210; 
Ziemssen's  motor  points  (with 
figures,  211  ;  difference  in  action 
of  galvanic  and  faradic  current, 
215  ;  estimate  of  activity  and  for- 
mulas used  in  testing,  218;  action 
on  sensory  nerves,  218  ;  app  ica- 
tion  for  rheumatism,  219  :  for  neu- 
ralgia,219  ;  for  nervous  centres — 
brain,  spinal  cord,  sympathetic, 
220  ;  for  improving  nutrition, 221  ; 
lor  special  organs — eje,  ear,  la- 
rynx, phrenic  nerve,  bowels,  blad- 
der, uterus,  penis,  &c.,  221  ;  diag- 
nostic significance  of  tests,  222  ; 
electrical  form ulii?,  218;  delusions 
of  insane  regarding  electrical 
agents,  241 

Electro-magnetic  instruments,  209 

Elements,  galvanic  names  of,  205 

Elephantiasis,  97 


INDEX. 


525 


Emaciation,  28;  a  feature  in  mania, 
227 

Embolism,  of  retina,  141  ;  of  cere- 
bral arteries,  causing  hemiplegia, 
&c.,  181;  in  chorea,  197;  of  pul- 
monary artery,  a  cause  of  dys- 
pnoea, 2fi0  ;  a  cause  of  pulmonary 
abscess,  274 

"  Embonpoint,"  31 

Emesis,  see  Vmniting 

Emotions,  variations  of,  in  paraly- 
sis, 167,  168,  172;  influence  in 
producing  speech  in  aphasia  176  ; 
disturbance  in  hysteria,  190 

Emphysema,  chest  distorted,  43-3  ; 
displacement  of  heart  and  liver, 
(Fig    84),  486 

Emporte-pirce  histologique  (Du- 
chenne),  169 

Emprosthotonos,  194 

Empyema,  bursting  into  lung,  274 

Endo-metritis,  endo-cervicitis,  see 
Uterus 

Enteric  fever,  rise  of  temperature 
in  (diagram  of),  74  ;  period  of 
incubation,  106;  liability  to 
second  attack,  106  ;  eruption, 
112 

Enuresis,  179 

Epiglottis,  as  seen  in  larynx,  296 

Ephelis,  97 

Epigastri'j  region  and  contents, 478  ; 
pulsation  in,  455,  481  ;  tumors 
in,  501 

Epilepsy,  description  of  typical  at- 
tack, 187;  hystero-epilepsy,  188  ; 
"  Jaeksonian,"  191;  relation  to 
insanity  and  idiocy  in  family  his- 
tory, 252  ;  relation  to  menstrua- 
tion, 410 

Epileptic  hemiplegia,  170,  187 

Epileptic  mania,  187,  234.  254 

Ep  leptiform  convulsions,  187 

Epistaxis  in  hooping  cough,  270  ; 
various  causes  of  epistaxis.  279 

Epithelial  tube-easts,  373,  374  (Fig. 
47a),  371 

Epithelioma,  97 

Epithelium,  renal,  resembling  pus, 
371,377;  various  kinds  of  epi- 
thelium in  urine,  377  ;  renal, 
377  (Fig.  49),  377;  epithelium 
from  bladder,  ureter,  pelvis  of 
kidney  (Fig.  50),  377,  378  ;  tailed 
epithelium,  378;  squamous  va- 
ginal (Fig.  51),  378;  from  uterus 
in  leucorrhoe.i,  407 

Erb  on  reaction  of  degeneration  of 


muscles  (electricity),  217^;  form- 
ulae of  muscular  action,  218 

Erotomania,  229 

Eruptions  in  fevers,  88,  89  ;  cuta- 
neous, 91  ;  distribution  of,  97  ; 
elementary  lesions  in,  92  ;  second- 
ary, 96;  constitutional  disturb- 
ance in,  99;  causes  of,  100;  fe- 
brile eruptions.  105:  syphilitic, 
117 

Eustachian  tubes,  examination  of, 
144,  145 

Erysipelas,  93,  97  ;  period  of  incu- 
bation, 104  ;  liability  to  second 
attack,  106;  eruption  of  114;  in 
infants,  114  ;  in  dropsv,  114 

Erythema,  93,  97,  114 

Examination  and  reporting  of  med- 
ical crises  (Chapter  ii.),  53  ;  post- 
mortem examinations  (Chapter 
xvii.),  503 

Exanthemata,  as  a  class  (Willan), 
93 

Excitement,  cause  of  dyspnoea,  261 

Exophthalmos,  129;  exophthalmic 
goitre,  129  ;  and  insanity,  236  ; 
albuminuria  in,  376 

Expectoration,  section  on,  273;  how 
collected  and  examined  as  to  quan- 
tity, color,   smell,    tenacity,   <tc., 

273  ;  in  he;ilth,  273  ;  black  color, 
273;  I'rothy  mucus, 273  ;  purulent, 

274  ;  fibrinous  shreds,  274  ;  cheesy 
masses,  274;  calcareous  masses, 
274  ;  hydatids,  274  ;  of  blood,  275  ; 
rusty  expectoration,  275  ;  "prune 
juice,"  276  ;  like  red  currant 
jelly,  276  ;  microscopic  examina- 
tion of  crystals  in,  277  ;  lung 
tissue,  277  ;  how  to  search  for 
lung  tissue  in,  277;  tissue,  277; 
absence  of,  in  certain  pulmonary 
affections,  276 

Expiratory  murmur,  normal,  442  ; 
prolonged,  443 

External  division  in  case  taking,  55 

Eructations,  314 

Extra  current  (electricity),  208 

Eye,  examination  of  symptoms  con- 
nected with,  128  ;  works  of  refe- 
rence on,  128  ;  protrusion  of  eye- 
ball, 129;  eyelids,  inability  to 
close,  129  ;  droop  of  129  ;  para- 
lysis of  ocular  muscles,  130  ;  func- 
tions of  muscles,  132;  clinical 
significance  of  ocular  paralysis, 
134;  convulsive  movements  of 
muscles,  137;  conjugate  deviation 


526 


INDEX. 


of  eyes,  138;  optical  defects  of, 
138;  ophthalmoscopic  examina- 
tion, 140;  subjective  disorders  of, 
153;  strain  on,  155;  importance 
of  eyesight,  in  balancing  and  walk- 
ing in  ataxy,  173;  gnlvanism  for 
affections  of  eye,  221 
Eyelids,  piiralysis  of,  47,  129,  136, 
163  ;   convulsive  movements,   138 

FACE,  paralysis  of,  see  Facial 
nerve,  162;  pallor  of,  in  epi- 
lepsy, 187;  local  spasms  of  facial 
musBles,  192;  flushing  and  livid- 
ity,  194,  265 

Facial  nerve,  testing  of,  162  ;  para- 
Ij'sis  of,  action  of  two  kinds  in 
electricity,  215  (see  preceding 
entries) 

Facies  Hippocratica,  38 

Fecal  vomiting,  312 

Feces,  appearance  of  (see  Motions, 
319  ;  state  of  bowels,  316) 

Fall  of  temperature  before  death, 
73  ;  in  crisis,  75  ;  fallacies  in 
judging  of,  76 

Family  history,  63;  importnnce  of, 
in  acute  diseases,  65  ;  inferences 
from,  65;  fallacies,  66;  in  in- 
sanity,  252 

Fainting  fits,  186  ;  in  uterine  dis- 
orders, 410 

False  croup,  271;  false  cords  in 
liirynx,  296 

Faradic  current,  208  ;  use  in  excit- 
ing muscles,  211  ;  different  action 
from  galvanic,  217;   tests,  222 

Fatty  acids  in  vomited  matter,  313  ; 
fatty  matter  in  motions,  324; 
fatty  tube-casts  (Fig    48«),  376 

Farcy,  affection  of  glands  in,  121 

Fauces,  examination  of  (Chapter 
X.),  287;  method  of  inspection, 
287 ;  morbid  appearances  in, 
288  ;  catarrh  of,  288  ;  scarlatina 
affecting,  289  ;  diphtheria  affect- 
ing, 289  ;  ulcers  in,  290  ;  phleg- 
monous inflammation  of,  290  ; 
syphilis  affecting,  291  ;  destruc- 
tion of  tissue,  291  ;  irritation  of, 
causing  vomiting,  309 

Favus,  y6,  97,  163 ;  parasite  in 
(Fig.  20),  103  ;   of  nails,  118 

Feathers  in  urine  (Fig.  56,  1),  381 

Feet,  swelling  of,  in  infancy,  192 
(see  also  Dropsy)  ;  inversion  of 
feet  in  infancy,  19  2 


Fehling's  copper  test  solution  for 
sugar,  358 

Female  organs,  disorders  of  (Chap. 
XV  ),  399 

Fenwiok,  Dr.,  on  detection  of  lung 
tissue  in  sputum,  277 

Ferguson's  speculum,  422 

Fermentation  in  vomited  matters, 
312;  in  stomach,  lactic,  butyric, 
and  alcoholic,  315  ;  acid  fermen- 
tation of  urine,  353  ;  test  for 
sugar  in  urine,  358  ;  quantitative, 
359  ;  torulae  in  saccharine  urine, 
359  ;  torula  eerevesise  (Fig.  55), 
380 

Festination,  172,  173 

Fever,  physiognomy  of,  43  ;  hectic, 
44  ;  general  symptoms  of  febrile 
state,  86;  clinical  significance  of 
febrile  state,  88  ;  rashes  in,  105; 
period  of  incubation  in  fevers, 
106  ;  liability  to  second  attacks 
of  fevers,  106  ;  cause  of  delirium 
in,  198,  249  ;  cause  of  vertigo  in 
early  stage,  201  ;  as  a  cause  of 
insanity,  237  ;  respiration  quick- 
ened in,  258 ;  hemorrhages  in 
fevers,  280 

Fibrinous  shreds  and  easts  in  fibrin- 
ous bronchitis,  croup,  Ac,  274 

Fibroma  molluscuni,  97 

Fifth  nerve,  in  nose,  147;  in  tongue, 
149  ;   testing  of,  161 

Filaria  sanguinis  hominis  in  chylu- 
ria,  &c.,  285 

First  nerve,  see  Nose,  146,  160 

Fissu  es  in  skin,  96 

Flashes  of  light,  156  ;  in  paralysis, 
194 

Flatulence  as  a  cause  of  palpitation, 
262  ;  of  thoracic  and  cardiac  pain, 
264;  forms  of,  314;  simulating 
ascites,  340 

Flavors,  relation  to  smell,  147 

Flax  fibres  in  urine  (Fig.  565.),  381 

Flea  bites  and  typhus  rash.  111 

Flomiatiu,  45 

Flooding,  404 

Fluctuation  in  ascites,  340 

Flushing,  of  face,  86  ;  feeling  of 
flushing,  160  ;  flushing  and  livid- 
ity  in  p.iralysis,  194  ;  at  change 
of  life,  406 

Fibres,  yellow  elastic,  in  sputum, 
277 

Fits,  various  kinds  of,  185,  186  ; 
faintingfits,  186;  convulsion  fits, 


INDEX. 


527 


187  :  hj'sterical  fits,  190  ;  plastic 
rigidity,  191;  "  inwdid  ffts," 
188 

Foetor  from  nose,  147  ;  in  expecto- 
ration, 274 

Poetus,  movements  of,  414  ;  sounds 
of  heart,  414 

Folic  circuhiire,  240 

Fomites,  106 

Fontanelle,  state  of,  in  fits,  189, 
204 

Food,  habitual  character  of  (case- 
taking),  fil  ;  articles  of,  as  caus- 
ing eruptions,  100  (see  Chapter 
xi.,  p.  803  pr'ssim) 

Formication.  160 

Fi  ster  (Michael),  on  details  of  urea 
analysis,  391 

Foulis  (Dr.),  on  Auto-Iaryngoscopy, 
295 

Fourth  nerve,  161 

Fragilitas  crinium,  97 

Framboesia,  96 

Franklinie  electricity,  209 

Fremitus,  vocal,  447;   hydatid,  489 

Frenum  linguae,  ulcer  on,  in  per- 
tussis, 270 

Frictional  electricity,  209 

Friction  in  abdomen.  342  ;  in  chest, 
446 

"  Frog"  or  thrush,  305 

Frothy  spit,  273 

Functional  cardiac  murmurs,  473 

Fungi  in  urine,  38'1  ;  mould  fungus 
in  urine  (Fig.  64),  380 

Furunculus,   97 

Furring  of  tongue,  305 

GAIT,  see  Walking 
Gairdner,  on  cardiac  murmurs, 
465  et  seq. 

Gall-stones  in  motions,  324,  335;  a 
cause  of  jaundice,  333  ;  test  of, 
by  obtaining  cholesterine,  335 

Galvanic  instruments,  207  ;  gal- 
vanic current,  207;  galvanic  cau- 
tery, 209  ;  galvano-puncture  of 
aneurism,  210  ;  galvanism  for 
muscles,  213;  different  action 
from  faradic,  on  muscles,  215  ; 
test.s  for  muscles,  222 

Gangrene,  odor  of,  in  expectoration, 
274 

Garrod  (Dr.),  test  for  uric  acid  in 
blood,  126 

Gases,  irrespirable,  causing  lividity, 
&c.,  266;  irritating,  causing 
cough,  271 


Gasserian  ganglion,  paralysis  in- 
volving, 162 

Gee  (Dr.),  on  shape  of  chest,  431 

General  paralysis,  see  Paral3'sis 

Genital  organs  in  the  male,  dis- 
turbances of  (Chapter  xiv.),  396  ; 
impotence,  396  ;  excessive  apti- 
tude for  vener.v,  397  ^  priapism, 
397;  masturbation,  397  ;  seminal 
discharges,  397  ;  genito-urinary 
system,  in  case-taking,  58 ;  dis- 
orders of  female  genital  organs 
(Chapter  xv  ),  399;  works  of 
reference  on,  399  ;  menstruation 
and  its  disorders,  399  ;  amenor- 
rhoea,  401  ;  suppiession  of  menses, 
403  ;  dysmenorrhoea,  405 

German  measles,  period  of  incuba- 
tion, 106  ;  liability  to  second  at- 
tack, 106;  rash,  110 

Giddiness,  see  Vertigo 

Gingivitis,  see  Inflammation  of 
gums,  330 

Glanders,  affection  of  glands  in,  122 

Glands,  affections  of,  1 19  ;  bronchial 
glands  affected,  271  ;  hemorrhages 
and  lymphatic  glandular  affec- 
tions, 281  ;  mesenteric  enlarged, 
343 

Globular  sputa,  274 

Globus  hystericu,*,  190,  315 

Glossitis,  307 

Glosso-labio-larj'ngeal  paralysis, 
47,  163,  164 

Glosso-pharyngeal  nerve,  149,  164 

Glottis,  spasm  of,  186,  194,  265, 
269  ;  irritation  and  spasm  of, 
from  laryngeal  irritation,  foreign 
bodies,  &c.,  270,  271,  272,  299, 
300 

Glycosuria,  see  Sugar  in  urine, 
357 

Goitre,  exophthalmic,  129,  and  in- 
sanity, 236 

Gonorrhoea,  rheumatism  in,  124; 
gonorrhoeal  synovitis,  124  ;  pyae- 
mia in,  125  ;  pain  in  micturition, 
395 

"Goose-flesh,"  43,  160 

Gout,  cachexia  in,  41  ;  group  of 
allied  diseases,  affection  of  joints, 
124;  heredity  and  habits,  influ- 
ence of,  125;   lead,   influence  of, 

125  ;  uric  acid  in  blood,  test  for, 

126  ;  chronic  gout,  126  ;  a  cause 
of  insanity,  235 

Gowers  (Dr.),  method  of  counting 
blood  corpuscles,  284 


528 


INDEX. 


Grandeur,  delusions  of,  in  general 
paralysis,  241 

Granular  tube-casts  {Fig.  47  b), 
376  ;  granular  corpuscles  in  urine, 
377 

Gravel  in  urine.  366,  380  et  seq.  ; 
pain  fr(im,  396 

Graves's  disease,  see  Exophthalmic 
goitre 

Graves  (Dr.),  on  myoidema,  34 

Grimaces  in  chorea,  197  (see  also  p. 
192) 

Grinding  the  teeth,  329 

Grove'.-  battery,  207 

"  Growing  pains,"  124 

Grovpths  in  larynx,  299 

Growth  of  infant,  49 

Guaiac  test  for  blood  and  haemo- 
globin, 368 

Gumboil,  330 

Gums,  330  ;  swelling  of,  330  ; 
spongy,  330  ;  blue  and  red  line 
on,  330;  inflnmmation  of,  330; 
sordes  on,  331  ;  white  and  black 
patches,  331  ;  gustatory  nerve, 
149 

HABIT  of  body,  39  ;  habits  of 
patients,  61 

"  Habitus  depravatus,"  39 

llsematemesis,  275,  313 

Hfematocele,  pelvic,  426 

Hseuiatinuria,  368 

Heematoma  auris  in  general  paraly- 
sis, 243 

Hfematuria,  367 ;  guaiac  test  for, 
368 

Haemic  murmurs,  474 

Hasmochromometre,  use  in  an«mia, 
36,  286 

Haemoglobin,  determination  of 
quantity  in  blood,  285  ;  guaiac 
test  for,  308 

HEemophiiia,  280 

Haernoptysis,  274  j  fallacies  as  to, 
275 

Hair,  affections  of,  103;  grayness 
in  anassthesia,  162;  in  urine 
(Fig.  56  c),  381 

Hallucinations,  definition  of,  224 

Hammond's  athetosis,  171 

Hands,  -waving  motions  of,  in  fever, 
45  ;  inversion  of,  in  convulsion, 
191;  swelling  of  dorsum  in  infan- 
cy, 191 

Hayem  and  Nachet's  method  of 
counting  blood  corpuscles,  283 

Head,  blows  or  falls,  as  cause  of 


loss    of  hearing,   144  ;    of  smell, 
147;    of  insanity,  236 

Headache  in  fever,  86  ;  from  strain 
on  eyes,  155;  various  causes  of, 
204;  sick  headache,  coincident 
symptom.",  204 

Hearing,  test  of,  144 

Heart,  disease  of,  allied  to  chorea, 
197;  cause  of  paralysis,  194; 
palpitation  of,  256,  262  ;  dyspnoea 
from  heart  disease,  260 ;  irregu- 
luarity  of  action,  263;  pain  in 
cardiac  region,  264;  congenital 
defects  causing  lividity,  266 ; 
sounds  of  in  foetus,  414;  reso- 
nance of  heart's  sounds  from  dis- 
ease of  lung,  449  ;  physical  ex- 
amination, 449;  normal  heart, 
450;  percussion  of,  451  ;  normal 
percussion  (fig.  69),  452  ;  changes 
in  apex-beat,  453;  pulsations 
other  than  apex-beat,  455;  pul- 
sation in  vessels  of  neck,  466  ; 
changes  in  precordial  dulness, 
457;  increased  dulne.-s  from  hy- 
pertrophy (Fig.  70),  467;  from 
pericardial  effusion  (Fig.  71), 
45y  ;  tremor  or  thrill  with  action, 
458;  displacement  to  right  and 
left  (Figs.  72,  73j,  469,  460;  dis- 
placement in  emphysema  (Fig. 
84),  486  ;  sounds  of  heart,  461; 
phenomena  in  a  cardiac  revolu- 
tion (Fig.  74),  463;  sounds  al- 
tered in  character,  463  ;  echo  of, 
465,  474  ;  reduplication  of  sounds, 
464 ;  cardiac  murmurs,  464, 
476 

Heat  of  body,  increase  of,  68  (see 
also  Temperature)  ;  unequal  dis- 
tribution of  heat,  86  ;  sense  of, 
163 

Hectic  fever,  44;  diurnal  range  of 
temperature,  71;  inverted  type, 
71 

"Hedge-hog"  crystals  (Fig.  68), 
383 

Height,  relation  to  weight  (table), 
29  ;  increase  in  infancy,  49 

Hemeralopia,  167 

Hemi-auEesthesia,  162;  with  and 
without  paralysis,  167 

Hemi-chorea,  171,  197 

Hemiopia,  140,  166  ;  varieties  of, 
156 

Hemiplegia,  gait  in,  47  and  172 
definition  of,  166  ;  alternate,  166 
epileptic,   171;    in   chorea,    171 


INDEX. 


529 


unilnternl  convulsions  in,  171  ; 
post  hemiplegic  chorea,  171  ; 
connection  with  aphasia,  177; 
clinical  significance  of,  ISO  ; 
causes  of,  ISO;  and  paraplegia 
ciimbined,  180;  in  pregnancy, 
181. 

Hemorrhages,  cutaneous,  97  ;  in 
stn;illpos,  109  ;  in  typhus  in  skin, 
111;  suljcutaneous,  115;  joint 
affections  anil  hemorrhiiges,  127; 
in  retina,  142  ;  in  brain  as  cause 
of  hemiplegia,  180,  280  ;  hemor- 
rhage a  cause  of  vertigo,  201  ; 
from  lungs,  275  ;  section  on  he- 
morrhages of  various  kinds,  2(9; 
cause  of,  2s0  ;  from  hepatic,  car- 
diac, and  renal  disease,  2S0  ;  in 
splenic  disease,  281  ;  from  sto- 
mach, 3K^  ;  from  bowels,  320; 
in  gums,  330  ;  in  jaundice,  336, 
3M  ;  by  way  of  urine,  3fi7  ;  vica- 
rious in  amenorrhcea,  402  ;  from 
womb,  403,  406  ;  in  carcinoma 
uteri,  426 

Hemorrhagic  diathesis,  280 

Hemorrhoids,  bleeding  from,  280 

Hereditary  tendencies,  see  Family 
history 

Herpes,  94 

Hiccup,  314 

"  Hide- bound,"  339 

Hills,  climbing  of,  causing  dyspnoea, 
261 

Hip-joint  disease,  effect  on  walking, 
174 

Hemiernnia,  310 

Hippocrates  on  acute  collapse  {Fa- 
des Hippocrotica),  38  ;  on  Car- 
phologia  in  fevers,  45 ;  Hippo- 
cratic  suecussion,  480 

Hirsuties,  97 

History,  personal,  58;  of  illness, 
58;  of  previous  health,  60;  so- 
cial, 61  ;  of  habits,  61  ;  of  health 
in  children.  69 ;  family  history, 
63 

Histrionic  spasm,   192 

Hoarseness,  270,  272;  an  indica- 
tion for  laryngoscopy,  297 

Hodgkin's  disease,  120 

Homicidal  insanity,  237 

Homonymous  diplopia,  132 

Hooklets  from  hydatids  in  fluids 
(Fig.  42),  3-16 

Hooping-cough,  269 

Horripibition,  43,   160 

Humming-top  sound  in  veins,  475 

45 


Hurrying,  cause  of  dyspnoea,  261 

Huiohinson,  on  notched  teeth  in 
hereditary  syphilis.  328 

Hyaline  tube-casts,  374  (Fig.  46) 

Hypo  bromite  of  soda  for  urea  ana- 
"lysis,  392 

Hydatids,  in  spit,  275,  277  ;  vomit- 
ed, 313;  in  motions,  324  (Fig. 
42),  346;  fluid  removed  from, 
346  ;  fremitus  in  percussing  liver, 
4S9,  500 

Hydreneephaloid,  189;  sleepiness 
'in,  204 

Hydrocephalus,  189  ;  sleepiness  in, 
204 

Hydrocephalic  idiot,  50 

Hj'drometer  for  urine,  352 

Hydronephrosis,  fluid  from,  346  ; 
urine  from,  352 

Hydro-peritoneum,  339 

Hydrophobia,  194 

Hydrorrhcea  gravidarum,  408 

Hyoscyamus,  cause  of  spectral  il- 
lusions,  199 

Hyper  1  sthesia,  152,  160;  in  men- 
"ingitis,  168 

Hyper-dicrotism  in  pulse,  84 

Hyperidrosis,  97 

Hyper-involution  of  uteru',  421 

Hypermetropia,  138;  manifest  and 
latent,  139;  cause  of  strain  on 
eyes,  155 

Hyper -pyrexia,  72,  73  :  in  rheuma- 
tism, 124  ;  in  chorea,   197 

Hypertrophy  of  heart  (Fig.  70),  457 

Hypertrophy  and  atrophy,  32  ;  ap- 
parent hypertrophy  of  muscles,  170 

Hypochondriac  regions,  their  situix- 
tion  and  contents,  478;  tumors 
in,  501 

Hypogastric  region  and  contents, 
4IS  ;   tumors  in,  501 

Hypoglossal  nerve,  165 

Hysteria,  fits  in,  with  swooning, 
186;  eonvuliive  fits,  188;  hyste- 
rical fits,  190;  hysterical  mania, 
22S  ;  dyspnoea  in,  267 

Hystero-epilepsy,  188 

ICHTHYOSIS,  95,  97 

A     Icterus,  see  Jaundice,  332 

Idiocy,  physiognomy  of,  49  ;  section 

on  idiocy,  247 ;  hereditary,  253 
Iliac    regions,    situation    and    con- 
tents, 478;   tumors  in,  501 
Illusions,    in    delirium,     198;   from 
hyoscyamus,    199 ;   definition    of, 
224 


630 


INDEX. 


Imnge?,  fnlse  images,  see  Diplopia 

Imbecility,  248 

Impetigo,  95,  97 

Iinpcitence,  421;  in  paralysis,  182; 
electricity  for,  222 

Impulsive  insanity,  2.38 

Incontinence  of  urine,  178 

Incubation  of  infectious  fevers,  106 

Indecency,  see  Obscenity 

Indigo  in  urine,  355 

Induced  currents,  induction  appa- 
ratus, 207 

Induration  of  cellular  tissue,  339 

Infancy,  physiognomy  of,  disorders 
of,  49  ;  increase  in  stature  in,  49; 
history  of  illness  in,  59 

Infantile  paralysis,  see  Paralysis 

Infarctions,  pulmonary,  causing 
haemoptysis,  276 

Infections  in  cutaneous  eruptions, 
100 

Inflammations  as  cause  of  pyrexia, 
90 

Influenza,  catarrh  and  cough  in,  271 

Insanity,  physiognomy  of,  48 ; 
chapter  viii.  on  insanity,  224 ; 
works  of  reference  on,  224  ;  chief 
forms  of  insanitj',  225;  premoni- 
tory mental  symptoms,  225  ;  in- 
sane temperament,  228  ;  relation 
of  insanity  to  bodily  disorders, 
menstruation,  sexual  organs, 
pregnancy,  228 ;  of  lactation, 
232;  alcoholic  insanity,  232; 
syphilitic,  233;  epileptic,  234; 
phihsical,  235  ;  impulsive,  237  ; 
moral,  238;  partial,  238;  circu- 
lar, 240  ;  monomania,  240;  gene- 
ral paralysis,  241;  dementia,  245: 
idiocy,  247  ;  diagnosis  of  deliri- 
um from  insanity,  248  :  mode  of 
examining  an  insane  person,  250  ; 
family  history,  252  ;  question  of 
asylum  treatment,  253 
Intemperance,  in  case-taking,  62  ; 
cause  of  delirium,  199  ;  cause  of 
insanity,  232;  of  mania,  228;  of 
general  paralysis,  244 
Intestines,    physical     examination 

of,  49li ;   see  also  Bowels 
Intermission  in  pulse,  81 
Internal  division  in  case-taking,  56 
Interrupted  current,  208 
Inspection  of  chest  as  to  lungs,  430  ; 
as   to  heart,   449  ;    of  abdomen, 
479 
Involuntary  movements  in  paraly- 
sis, 170 


Involution  of  uterus,  420,  421 
Iodide  ofpotassium,  rash  from,  102; 

salivation  from,  307 
Ireland,  (Dr.)  on  idiocy,  49,  248 
Iritis,  128.  135 
Iris,  paralysis    of,    133,   135;    (see 

also  Pupil)  ;  tremulous  iris,  137 
Irregularity   of  pulse,  81  ;    tracing 

of,  85 
Itch  insect  (Fig.  IS),  98 
Itching  in  skin  diseases,  99  ;  at  anus 

and   urethra,    100;    in   jaundice, 

100;  from  opium  and  arsenic,  100 

''TACKSONIAN  Epilepsy,"  191 
V  Jaundice  (chapter  xii),  332  ; 
works  of  reference  on,  332;  tests 
of  and  states  resembling  jaundice, 
332,  333;  urine  in,  333;  tube- 
casts  in  urine,  376;  stools  in,  333; 
obstructive  and  non-obstructive, 
333 ;  causes  of  obstruction  of 
ducts,  333  :  rigors  in,  334  ;  hem- 
orrhages, 335  ;  non  obstructive 
jaundice,  causes  of,  335;  jaun- 
dice in  infancy,  335;  concur- 
rence of  jaundice  and  dropsy, 
334,  345;   epidemic,  336 

Jaw,  spasm  of   193 

Jelly,  "  red-currant  jelly"  exijecto- 
ration,  275 

Jenner,  Sir  Wm.,  on  Rickets,  42 

Jerky  respiration,  443 

Johnson  (Dr.  George)  on  Auto- 
La  ryngoscopy,  296 

Joints,  affections  of,  122 ;  pains 
with  subcutaneous  hemorrhages, 
127;  effect  of  walking  on  joint- 
disease,  174;  in  hemorrhagic 
diathesis,  280 

KA  =  Cathode,  218 
Kl  =  Klang    (electrical   sym- 
bol), 218 

Kidney,  affection  of,  in  gout,  126; 
diseases  of,  albuminuria  in,  266; 
suppuration  in  pelvis  (pyone- 
phrosis), 372,  373;  physical  ex- 
amination of,  492;  floating  or 
movable,  493 

Kinks  in  coughing,  269;  "  dumb- 
kinks,  "269 

Kleptomania,   237 

LABILE     currents     (electricity), 
215 
Laborious  breathing,  258,  266 
Labor,  insanity  in,  231 


INDEX. 


531 


Lnbio-glosso-laryngeal  paralysis, 
47,  164 

Labyrinth,  affections  of,  with  tinni- 
tus and  vertigo,  158 

Lactation,  insanity  of,  232 

Lagophthalmos,  129 

Lamp  for  laryngoscope,  292 

Laryngeal  (labio-glossal)  paralj'sis, 
47,  164 

Laryngismus  stridulus,  186,  194, 
266,  269,  271 

Laryngitis,  270,  271 

Laryngoscope,    method    of     using, 

292  ;     la"ip    for,     292 ;     mirrors, 

293  :  autolaryngoscopy,  various 
methods,  294,  296  ;  when  to  be 
used,  296  :  works  of  reference  on, 
302 

Larynx,  nervous  disorders  of,  164, 
185,  194;  galvanism  for,  221;  ir- 
ritation and  disease  of,  causing 
cough,  271  ;  foreign  bodies  in, 
272;  examination  of  (chapter  x), 
287;  method  of  examining  by 
laryngscope,  292;  appearances 
normally,  294;  examining  by 
finger,  296  ;  morbid  appearances, 
297  ;  when  larynx  must  be  ex- 
amined, 297  ;  catarrh  of  larynx, 
acute  and  chronic,  297,  298; 
phthisis  of,  298;  syphilitic  disease 
of,  298  ;  inflammation  of  carti- 
lages, 298  ;  croup  in  diphthe- 
ria, 298  ;  oedema  glottidis,  298  ; 
growths  in,  299;  paralysis  and 
spasm  of  cords,  299  ;  laryngeal 
afi'ections  of  voice  and  cough, 
299  ;  aneurisiual  affections  of, 
299  ;  works  of  reference  on,  302 

Laughing,  test  by,  in  facial  paraly- 
sis, 162  ;  undue,  in  paralysis, 
168  ;   in  hysteria,  190 

Lead,  influences  of,  in  gout  and 
renal  disease,  125  ;  paralysis, 
183 ;  influence  of  electricity  in 
lead  paralysis,  216;  blue  line  on 
gums,  330 

Leclancbe  battery,  209 

Lens,  crystalline;  opacities  in,  156 

Lenticular  spots,  113:  lenticular 
ganglion,  see  Third  nerve,  Ac- 
commodation, Pupil 

Lepra,  95,   97 

Leucocytes  in  urine,  371 

Leucocythseraia,  see  Leukeemia 

Leucoderma,  117 

Leucnrrhcea,  discharge  in  urine. 
356  ;     physiological    before,    and 


after  menstruation,  398j  section 
on  Leuchorrhoea,  407  ;  fetid  dis- 
charge, 426,  427 
Leukajmia,  glands  in,  120;  blood 
in,  120  ;  splenic  and  lymphatic, 
120  ;  and  hemorrhages,  281  ;  ex- 
amination of  blood  in,  281  (see 
also  Spleen) 
Levator  palpebrse,  paralysis  of,  129, 

135 
Lewis  (Filaria  sanguinis  hominis), 

285 
Lichen,  94,  97 
Liebig's   metliod  of  urea   analysis, 

390 
Light,  flashes  of,   156;   intolerance 

of,  157,  227 
"  Light  weight,"  29 
Limbs,  paralysis  of,  166,  167;  state 
of  in  paralysis,  169  ;   contractions 
and  shaking  of  in  paralysis,  170  ; 
involuntarjf  movements  in,  171 
Lime,  carbonate  of,  in   urine,  386  ; 
'       phosphate  (Fig.  61),  384  ;  oxalate 

of  (Fig.  62),   385 
Lineaj  albicantes,  480 
Lithates,  see  Urates 
Lithic  acid,  see  Uric  acid 
Lips,    quivering    of,    171,   243    (see 
also   labio-glossal  paralysis);  pa- 
ralysis    of,     tested     by     labials, 
165 
Liquor  potassse,  test  for  sugar,  360  ; 

for  pus  in  urine,  370 
Liver,  abscess  of,  opening  into  lung, 
274;  cirrhosis,  cancer,  Ac.,  caus- 
ing drop.-iy,  343;  cirrhosis,  344; 
hemorrhages  from  disease  of,  345  ; 
cancer  of,  345  ;  nodulation  of, 
344  ;  size  of,  344,  345  ;  physical 
examination  of,  484;  dulness, 
natural,  enlarged,  diminished, 
displaced,  485,  486  ;  density- 
smoothness,  irregularity,  488; 
notch  of,  488  ;  gall-bladder,  488  ; 
local  enlargement,  483  ;  diminu- 
tion, 489 ;  pain  and  tenderness, 
489  ;  hydatids  of,  500  ;  see  also 
Jaundice 
Lividity   of  face    in  Facies   Ilippo- 

cratica,  38  ;   in  paral3'sis,  194 
Lividity,     in     dyspnoea,     265 ;     of 

tongue,  307 
Locomotor  ataxy,  see  Ataxy 
Lumbago,   185  ;   various  causes  of, 

21)5 
Lumbar  regions,  situation  and  con- 
tents, 478  ;   tumors  in,  501 


532 


INDEX. 


Lunatic,  mode  of  examining,  250  ; 
see  Inpfinity 

Lung,  absccss  of,  274;  tissue  of, 
in  sputum,  274;  277  (Fig.  29), 
279 ;  hemorrhage  from,  275  ; 
physical  examination  of  lungs, 
429;  inspection  of  chest,  4;^0 ; 
shape  of  chest,  430  ;  movements 
ot  chest  walls,  434  ;  palpation. 
435  ;  mensuration  of  chest,  436  : 
percussion,  437;  auscultation, 
440  ;  breath-sounds  and  respira- 
tory murmur,  442;  rales,  445; 
friction.  446 ;  metallic  or  am- 
phoric phenomena,  446;  vocal 
resonance  and  fremitus,  447 

Lupus,  96 

"Lusty,"  30 

Lymphadenoma,  Lymphoma,   120 

Lymphatic  glands,  see  Glands 

Lymphatic  leukaamia,  120;  exami- 
nation of  blood  in,  282 

Lysis,  76  ;  remitting  in  enteric 
fever,    76 

MACULiE,  96 
Magneto-electric        batteries, 
208 

^  =  micro-millimeter,  2§3 

Magnets  in  batteries,  207 

Male  organs,  disorders  of  (chapter 
xiv.),  696 

Malignant  disease,  cachexia,  43. 
See  also  Cancer 

Malla^^sez's  instrument  for  number- 
ing blood  corpuscles,  use  of.  in 
anaemia,  36  ;   description  of,  283 

Mammae,  charges  during  preg- 
nancy, 413 

Mania,  maniacal  delirium,  198; 
epileptic,  puerperal,  199,  231  ; 
section  on  varieties  of  mania, 
225;  acute,  226;  acute  delirious 
mania,  228;  mania  transitoria, 
228;  chronic  mania,  229;  hys- 
terical mania,  229;  mania  of  pu- 
berty, 229  ;  diagnosis  of,  from 
delirium,  248 

Margarine,  crystals  of,  in  vomited 
matter,  313 

Mastication,  muscles  of,  paralysis 
of,  161 

Mastoid  cells,  suppuration  in,  146 

Masturbation,  case-taking,  62  ;  sec- 
tion on,  397;  cause  of  convul- 
sions, 190  ;  in  insanity,  227,  230 

Measles,  catarrh  and  cough  in,  280  ; 
period    of  incubation,    106 ;    lia- 


bilitv  to  second  attack,  106  ;  rash 
in,  110 

Meatus  urinarius.  pain  in,  375; 
discharges  from,  397 

Meckel's  ganglion,  161,  162 

Medicines,  as  causing  cutaneous 
eruptions,  100;  as  causing  sali- 
vation, 306  ;  causing  odors  from 
patients,  158,  307;  causing  black 
stools,  320 

Meiliocanellata  (see  Taenia,  323) 

Medulla  oblongata,  affection  of,  164 

Melsena,  320 

Melancholia,  during  lactation,  232; 
section  on  various  forms,  238  ; 
simple  melancholy,  238;  hypo- 
chondriasis, 238  ;  acute  melan- 
ch(>lia,  239  ;  melancholy  with 
stupor,  or  melancholia  attonita, 
240 

Melnnopathia,   97 

Memory  of  words,  see  Aphasia,  175 

Meniere's  disease,  169 

Meningitis,  diagnosis  from  mania, 
250 

Menopause,  406  ;  insanity  at,  229 

Menorrhagia,  403 

Menses,  see  Menstruation,  399,  et 
seq.;  emansio  niensium,  401  ;  siip- 
pressio  mensium,  403  ;  menstrual 
molimen,  4  02  ;   cessation  of,  406 

Menstruation,  disorders  of,  in  in- 
sanity, 227,  229;  close  of,  and 
insanity,  229;  "vicarious"  (by 
lungs),  276  ;  normal  and  abnor- 
mal, 399,  401  ;  strain  of,  on  de- 
velopment of  patient,  4(12;  exces- 
sive, 403;  painful,  405;  cessation, 
406 ;  suppression  in  pregnancy, 
412 

Mensuration  in  examining  chest, 
436  ;   in  abdomen,  483 

Mentagra,  see  Sycosis 

Mercurial  tremors,  171  ;  salivation, 
307,  330 

Mesenteric  disease  causing  dropsy, 
343  ;  large  glands  felt  in,  343 

Mesmeric  trance,  195 

MetaU)umen,  347 

Metallic  phenomena  in  auscultation, 
446  ;  tinkling,  447  ;  echo  of 
heart's  sounds,  474 

Metrorrhagia,  403 ;  at  change  of 
life,  406  ;  in  cancer,  426 

Microcephalic  idiot,  49 

Micrometer,  ocular  in  square?,  and 
stage  micrometer  for  counting 
blood  corpuscles,  282 


INDEX. 


533 


Microsporon  Audouini,  103 

Microsporon  furfur  (Fig.  22),  116 

Micturition,  frequence  and  pain  in, 
394 ;  pain  in  from,  uterine  dis- 
order, 409 

Migraine,  310 

Miliaria,  94  ;  miliary  yesicles,  113 

Milium,   97 

Milk-teeth,  formula,  326 

Mitral  murmur,  area  of,  469 

Molluscum,  96,  97 

Monomania,  241 

Monoplegia,  166 

Moore's  test  for  sugar,  360 

Moral  perversity  in  mania  of  pu- 
berty, 229:  from  alcohol,  232; 
moral  insanity,  238 

Morbilli,  see  Measles 

Motes,  155 

Motions  from  bowels,  frequency  of, 
316  ;  consistency,  316,  320  ;  force 
and  straining  in  expulsion,  316; 
passed  in  bed,  316  ;  appearances 
of,  317;  consistency,  319;  size  of 
fecal  mjisses,  326;  "formed," 
320;  "psa-soup, "  "rice-water," 
&c.,  320;  color  of,  320;  clayey, 
321,  333;  black,  320;  bloody, 
320  ;  green  and  white,  321 ;  mu- 
cus in,  321 ;  pus  in,  321 ;  worms 
in  motions  (figures  of  thread- 
worms and  tape-worms),  322; 
hydatids  in,  322;  fatty  matter  in, 
322;  gall-stones  in,  324;  bones, 
coins,  teeth,  &c.,  324;  smell  of, 
324 

Motor-oeuli,  testing  of,  161 

Motor-points,  electrical,  Ziemssen's, 
210,  215 

Mottling  in  typhus.  111 

Mould  in  urine  (Fig.  54),  379 

Mouth,  temperature  taken  in,  70  ; 
paralysis,  163 

Mosa,  electric,  in  neuralgia,  219 

Muco-purulent  sputum,  273 

Mucus,  in  motions,  321;  "mucus 
disease,"  321;  in  urine,  354 

Mucous  rales,  443 

Mulberry  rash,  111 

Muguet,  distinction  from  diphthe- 
ria 290;  parasite  of  (Fig.  30), 
305 

Mumps,  121 

Murchison  (Dr.),  on  enlargements 
of  liver,  489 

Murmur,  see  Respiratory  murmur 

Murmurs,  cardiac,  465;  rhythm  of, 
465;    nomenclature  (note),  465; 


presystolic,  465;  direct  or  on- 
ward murmurs,  466  ;  indirect  or 
backward,  466  :  auricular-systolic 
(Fig.  75),  466;  Tentricular-sys- 
tolic  (Fig.  76),  467;  ventricular- 
diastolic  (Fig.  77),  467;  combi- 
nations of  murmurs  (Figs.  78-80), 
467,  468  ;  areas  of  murmurs  (Fig. 
81),  468,  471;  tabular  view  of 
valvular  murmurs,  473 

Murmurs,  arterial,  474 ;  venous, 
475;  pericardial,  472;  aneuris- 
mal,  473 ;  ansemic,  functional, 
haemic,  474 

Muscse,  fixed  and  floating,  155 

Muscles,  development  of,  in  in- 
fancy, 49  ;  tenderness  in  rickets, 
42;  muscular  prostration  in  fever, 
87:  pain  in,  168;  painful  cramps 
of.'  168;  state  of,  in  paralysis, 
169 ;  apparently  hypertrophied, 
169;  atrophy  of,  169;  examina- 
tion of  fragments,  169;  contrac- 
tions and  tremors  in  paralysis, 
170;  involuntary  movements  in 
paralysis,  170;  fibrillar  tremor  in, 
171;  plastic  rigidity,  191;  mus- 
cular atrophic  paralysis,  183  ,  ac- 
tion of  electricity  on,  210;  differ- 
ent action  of  faradic  and  galvanic 
current,  216;  difference  in  res- 
ponse to  galvanic  and  faradic 
currents  in  paralysis,  222,  223 ; 
Erb's  reaction  of  degeneration, 
223;  absence  of  response  to  elec- 
tricity, 223  ;  fibres  in  urine  (Fig. 
56  /,),  581.     See  also  Myoidema 

Muscular  sense,  153 

Mussitatio,  46 

Mycelium,  104 

Myoidema,  33,  note 

Myopia,  138 ;  cause  of  strain  on 
eyes,  155 

Myosis,  spinal,  136 

NACHET,   Hayem   and   Nachet's 
method  of  counting  blood  cor- 
puscles, 283 
Noevus,  97 

Nails,  affections  of,  curving,  white 
marks,   shedding  of,    118;    para- 
sites in,  119 
Narcotics,  as  cause  of  coma,  196 
Nares,  fluids  from,  causing    cough, 
270  ;  bleeding  from,  279  ;  exami- 
nation  of   (Chap.  X.),  287;    me- 
thod of  examination,  301 
Naunyn  on  cardiac  murmurs,  469 


45 


534 


INDEX. 


ITeck,  spasm  of  muscles  of,  192: 
convulsive  twitohirgs  of,  193; 
wry-neck,  193:  fixity  of  muscles 
in  atlantoid  disease,  193 

Keck,  pulsation  in  vessels,  456 

Nerves,  cranial,  testing  of,  129, 
160:  first.  161  (146,  158)  ;  scetnui, 
161  (138,  143.  153,  157);  third, 
161  (128.  135.  154.  155)  :  fourth, 
161  (133,  135.  Vab):f/th,  161 
(147)  ;  sixth,  162  (129,  135,  154)  : 
seventh— facial ,1(12  (]i9):  seventh 
—antiitory,  163  (144,  158):  eighth 
— glosso  jiharyngeal,  164  (48): 
eighth — spiiial  accessory,  164: 
eighth — pneumogastrie,  164  : 
ninth,  165 

Nervous  diseases,  physiognomy  of, 
46  :  group  of  allied  diseases,  65  ; 
albuminuria  in,  366 

Nervous  system,  in  case  taking. 
57 ;  symptoms  of  disorder  in 
(Chap,  vi  ),  166  ;  works  of  refer- 
ence, 128,  166  :  nervous  dyspnosa, 
267  :  organs  c.f  special  sense,  128; 
subjective  disorders  of  special 
senses,  153  ;  cranial  nerves,  150  ; 
paralysis,  166:  neuralgia,  184; 
fits,  185:  twitehings,  197:  deli- 
rium, 198:  vertigo,  299:  sleep, 
201  ;  headache,  204;  pain  in 
back,  205 

Nettle-rash,  see  Urticaria 

Neuralgia  in  skin  aiseases,  99:  with 
paralysis,  169:  with  anaesthesia. 
152:  in  ataxy,  168;  pains  in  in- 
fantile paralysis,  169  :  section  on 
neuralgia.  Ib4  :  reflex  pains  simu- 
lating. 184;  general  state  in,  184; 
electricity  in,  219 

Neuritis,  184 :  optic.  141;  optic 
neuritis  descendens,  143 

Neuroma,  184 

Night  blindness,  157 

Ni^ht-mare.  203 

Night  terrors.  203 

Night-walking,  203 

Nipples,  see  Mammae 

Ninth  nerve,  165 

Nitrate  of  silver,  discoloration  from, 
115 

Nitric  acid  test  for  albumen,  362  ; 
quantitative,  363 

Nitrogenous  principles  in  urine,  es- 
timation of,  390 

Nodding  in  shaking  palsy,  172 ; 
nodding  convulsions,  172,  193 

Nodosity  of  joints,  122 


Noises  in  ear,  158 

Nose,  examination  of  146  :  running 
from.  147  ;  fetor  from,  147 

Nose,  picking,  100,  280  ;  action  of 
dilator  narium,  in  dyspnoea.  259; 
bleeding  from,  in  whooping- 
cough,  269 

Numbness,  160 

Nummular  sputa,  274 

Nutrition,  galvanism  for  improv- 
ing.  221 

Nycturia,  179 

Nymphomania,  229 

Nystagmus,  138 


'FFNITiNG,    opening 

(electrieitv) 


of  circuit 


217 


(E' 

Obesity,  32 

Oblique  muscles  of  eye,  132,  133, 
134 

Obliquity  in  objects  seen,  129.  133 

Obscenity  in  insanity,  227.  231,  242 

Ocular  muscles,  paralysis  of,  129  ^ 
functions  of  (table),  132;  results 
of  paralysis  (lable),  133;  clinical 
significance  of,  134  :  convulsive 
movements,  13S  ;  asthenopia,  154; 
paralysis  in  svphilitic  insanity. 
234 

(Edema,  of  glottis,  298  ;  (see  also 
Catarrh  of  larynx,  297)  ;  section 
on  cedema,  337 ;  of  feet,  337 ; 
of  upper  part  of  body.  337  ;  of 
hands  and  feet  in  infants,  338 

OEsophagus,  spasms  of,  194;  oeso- 
phageal vomiting.  311 

Oidium  albicans  fFig.  30),  306 

Oil  in  motions,  324  ;  in  tube-casts 
(Fig.  4Sa),  396  ;  globules  in  urine 
(Fig.  56e),  3S1 

Oinomania,  233 

Olfactory  nerve,  160 

Onward  cardiac  murmurs,  466 

Orihopncea,  260 

Os  (uteri),  see  TTterus 

Opacity  of  cornea,  128 

Opaque  granular  tube-casts,  374 

Ophthalmoscope,  examination  of 
eye,  140  :  significance  of  appear- 
ance in  diagnosis,  142 

Opisthotonos,  approach  to  this  in 
infantile  spasms,  192 ;  character 
of,  193 

Opium,  influence  on  pupils,  136  ; 
extreme  efieet  in  renal  disease  in 
causing  coma,  196,  204;  a  cause 
of  insanity,  236 

Optical  defects  of  eye,  138 


INDEX. 


535 


Optie-nerve,  field  of,  and  vision  in 
oflFeetions  of,  139;  ophthalmos- 
copic examination,  140,  141,  142, 
143  :  testing  of,  161  ;  atrophy  in 
general  pnralTsis,  244 

Onychia,  97,  119 

Orbicularis  palpehrarum,  193 

Organic  dementia,  246 

Organisms,  living  in  blood,  2S5 

Otfirrhcea,  145 

Ovaries,  disease  of,  a  cause  of  in- 
sanity, 229  ;  dropsy  of,  physical 
signs  from  percussion,  &c.  (Fig. 
41),  342,  498  ;  fluid  removed  from 
ovarian  cysts,  346  :  from  paro- 
varian cysts,  347  ;  pear-shaped 
cells  in  fluid  from  malignant  dis- 
ease, 348;  absence  of,  causing 
amenorrhoea,  401  ;  pains  in  dys- 
menorrhoea,  405  ;  pelvic  ovarian 
tumors,  426 ;  tumors  and  cysts, 
499 

Ovula  nabothi,  424 

Oxalates  in  urinary  sediments,  356 
(Fig.  62),  385;  oxaluria,  386 

O.xyurides  vermiculares  (Figs.  32, 
33),  322 

Ozaena,  147 

Ozonij  ether  -veith  guaiae,  test  for 
blood  in  urine,  368 

PAR.\LYSIS,  physiognomy  of,  47; 
paralysis  of  ocular  muscles, 
129;  of  cranial  nerves,  160;  in- 
vestigation of  paralysis,  166  ;  gen- 
eral paralysis  of  the  insane,  47  ; 
fibrillar  tremor  in,  171  :  walking 
in,  171,  172,  174;  section  on 
symptoms  and  diagnosis  of,  241  ; 
distribution  of  paralysis,  166  ; 
"crossed"  paralysis,  166  ;  of  spe- 
cial limbs,  muscles,  nerves,  or 
functions,  166,  167;  state  of  Intel 
ligence  and  emotions  in  paralysis, 
167,  168;  prodromata  and  warn- 
ings of  paralysis.  167  ;  pain  and 
paralysis,  168;  rheumatic,  169; 
state  of  muscles  and  limbs  in  pa- 
ralysis, 169  ;  involuntary  move 
ments  in,  170;  after  epilep.«y, 
170;  choreic  movements  and  shak- 
ing in,  171  ;  reflex  actions  in,  172: 
shaking  palsy,  paralysis  agitans, 
171  ;  walking  affected  in  paraly- 
sis, 171,  174:  scrivener's  palsy  or 
writer's  cramp,  177  ;  of  bladder  | 
and  rectum,  178  ;  of  sphincters, 
178 ;   clinical  significance  of  pa-  , 


ralysis,  ISO;  diphtheritic,  182; 
of  extensors  of  arms,  183  ;  lead 
paralysis,  133;  affection  or  escape 
of  supinator  longus,  183  ;  wast- 
ingpalsy,  183  :  traumatic  paraly- 
sis, 183  :  delusions  in  paralysis, 
183  ;  sudden  paralysis.  194  ;  tests 
by,  and  uses  of,  electricity,  215  ; 
tests  by  electricity,  222  ;  paraly- 
sis of  vocal  cords,  299  ;  FACi.\t. 
PARALYSIS,  single  and  dcuble, 
47;  tests  of,  162:  double,  163; 
Glosso  labio-lap.vsgeal  para- 
lysis, 47,  164:  Infantile  par.a- 
LYSis,  walking  in,  173;  pecu- 
liarities of,  182 ;  electricity  in, 
216 

Parasites,  of  skin,  97  ;  itch  insect 
(Fig.  18),  98;  infection,  100:  pe- 
dicuUis  pubis  (Fig.  19)  101;  ex- 
amination of,  103;  of  hair,  103; 
para.^ite  on  tongue,  306  (see  Bac- 
teria in  blood)  ;  and  also  Worms 
and  Echinococci 

Paresis  (.=light  paralysis),  see  Para- 
lysis ;  general  paresis,  see  Gene- 
ral paralysis 

Pain  and  numbness  in  same  parts, 
152,  160  ;  and  paralysis  in  same 
parts,  168;  muscular,  168;  elec- 
tric or  toothache-like  in  ataxy, 
168  ;  thoracic  pain,  256,  263  ;  in 
left  arm,  264  :  abdominal  and  in 
bowels,  lie.,  .317;  in  micturition, 
395;  in  pelvic  region,  409;  in 
back,  see  Menstruation,  Dysmen- 
orrhoea,  Ac. 

Pair,  galvanic,  20S 

Palate,  paralysis  of,  162  ;  nasal  tone 
from  paralysis  of,  175  :  arched  in 
idiocy,  49,  248 :  catarrh  of,  288  ; 
diphtheritic  affection,  289  :  de- 
struction of  in  syphilis,  291 

Palpation,  in  examining  lungs,  435  ; 
in  examining  heart,  450  ;  abdo- 
men, 482 

Palpebra,  paralysis  of  levator,  129, 
135  :  of  obicalaris,  129,  163;  con- 
vulsive movements  of,  138 

Palpitation  of  heart,  section  on, 
256,  262 ;  sense  of  palpitation  in 
epigastrium,  262  ;  in  uterine  af- 
fections, 410 

Pallor  of  complexion  in  anaemia,, 
35 ;   of  tongue,  307 

Palsy,  see  Paralysis 

Pancreas,  examination  of.  494 

Papilla,  optic,  see  Optic  nerve 


53G 


INDEX. 


Papulae,  93 

Paracentesis,  see  Tapping 

Piira;sthe.<i,i,  160 

Paralbunien  in  ovarian  fluids,  347 

Parametritis,  418,  424 

Paraplegia,  gait  in,  47,  173  ;  defini- 
tion of,  166  ;  paralysis  of  bladder 
and  rectum  in,  177;  reflex,  179; 
and  hemiplegia  combined,  181  ; 
syphilitic  disease  as  cause  of, 
ISl  ;  causes  of,  182  ;  hysterical 
paraplegia,  182 

Parotitis,  121 

Parovarian  cysts,  fluid  from,  347 

Patheticus  (nerve),   162 

Pavy's  copper  test  solution  for 
sugar,  357 

Pear-shaped  cells  in  ovarian  cancer, 
348 

Pectoriloquy,  448 

Pediculus  pubis  (Fig.  19),  101 

Pelvic  cellulitis,  420 

Pelvis,  symptoms  referred  to,  407; 
pain,  408  ;  examination  of,  inte- 
riorly, 414 

Pelvic  inflammations,  424 

Pelvi-peritonitis,  318 

Pemphigus,  94,  97 

Penis,  see  Chapter  xiv.,  396 

Percussion,  dulness  in  ascites  (Fig. 
40),  339  ;  dulness  from  great  dis- 
tension of  bowel,  341  ;  dulness  in 
ovarian  dropsy  (Fig.  41),  341; 
pulmonary,  437  ;  tympanitic  and 
dull,  438;  cracked-pot  sound, 
440  ;  area  of  normal  percussion 
of  heart,  liver,  and  spleen  (Fig. 
69),  462  ;  decrease  of  cardiac  dul- 
ness, 457  ;  increase  cf  same,  457  ; 
displacement,  458 ;  in  thoracic 
aneurism,  475  ;  abdominal  aneu- 
rism, 500;  auscultatory  percus- 
sion, 484 

Pericardium,  eifusion  into  (Fig. 
71),  458;  pericardial  murmurs, 
472 

Perichondritis,  laryngeal,  299 

Perihepatitis,  a  cause  of  jaundice, 
336  ;   of  dropsy,  344 

Periodontitis,  330 

Peritoneum,  pain  and  tenderness 
in,  311,  318  ;  fluid  in,  339;  in- 
flammation, with  effusion,  342 

Peritonitis,  317 

Perityphlitis,  318 

Perimetritis,   318,  424 

Pernicious  anaemia,  37  ;  small  red 
cells  in  blood,  285 


Perspiration  in  fevers,  44  |  absence 
of,  in  diabetes,  44  :  in  wiry  and 
corpulent  persons,  44 

Pertussis,  269 

Petechia3,  111.  115 

Peiit  mill.  1 88 

Petrosal  branch  of  Vidian  nerve, 
162,  163 

Phantom  tumor,  500 

Pharynx,  paralysis  of,  164;  catarrh 
of,  288;  retro-pharyngeal  abscess, 
292 

Phlegmonous  erysipelas,  114 

Phosphates,  precipitation  of,  on 
heating  urine,  fallacy  from,  361 ; 
with  pus  in  urine,  370  ;  deposits 
in  urine,  384;  "triple''  (Fig. 
60),  384  ;  phosphate  of  lime  crys- 
tals (Fig.  61),  385 

Phtheiriatis,  97 

Phthisis,  atrophy  of,  33  ;  physiog- 
nomic signs  of,  34  ;  Aretajus  on, 
39  ;  phthisical  insanity,  235  ; 
bronchial  phthisis,  270;  simulated 
by  foreign  bodies  in  bronchi,  272; 
of  larynx,  298  ;  red  lines  on  gums, 
330 

Photophobia,   157 

Photopsia,  156 

Phrenic  nerve,  electrical  excitation 
of,  221 

Phyma.  96 

Physical  diagnosis  or  physical  signs 
(Chapter  xvi.),  429 

Physical  examination  of  chest  and 
abdomen  (Chapter  xvi.),  429  ;  of 
lungs,  429;  of  heart,  449;  of  ab- 
domen, 478 

Physiognomy  of  disease,  25  (see 
names  of  special  diseases  in  in- 
dex) ;  references  to  works  on,  52 

Pica,  304  (also  name  of  type  some- 
times used  in  testing  vision). 

Pigeon-breast  (Fig.  65),  431 

Pigmentation  of  skin,  115 

Pimples,  92 

Pitting  in  dropsy,  337 

"  Fins  and  needles,"  160 

Pityriasis,  95,  96,  97;  pityriasis 
rubra,  96,  97 ;  pityriasis  versi- 
color, 116 

Plague,  glandular  affection  in,  121 

Plastic  rigidity,  191 

Play,  instinct  of,  50 

Plessor,  437 

Plethora,  37 

Pleura,  perforation  of,  as  cause  of 
dyspnoea,    260  ;    pleuritic    stitch, 


IXDEX. 


537 


263;  aflFections  of  ariving  dulness 
on  percussion,  4H9  ;  obscuring 
breath  sounds,  442  :  effusions, 
displacing  heart,  469,  460 

Pleurosthotonos,  104 

Plesimeter,  437 

Pneuino-thorax,  as  cause  of  dys- 
pnoea, 260  :  displacing  heart  and 
mediastinum,  459 

Pneuuio-gastric  nerve,  164 

Polar  method  (electricity),  219 

Polariscope,  test  for  suga  ■,  360 

Pollitzer's  bag  for  inflating  ear,  145 

Polyopia  monocularis,   154 

Polymorphism  in  skin  diseases,  117 

Pompholvx,   94 

Pomphi,'93 

Pons  Varolii ;  pupils  in  hemorrhage 
into,  137 

Porrigo,  95 

Portal  vein,  obstruction  of,  causing 
dropsy,  343 

Portici  dura,  testing  of,  162  ;  double 
paralysis,   47,  163 

Post-mortem   examinations   (Chap- 
ter xvii.),  503:   instruments  and 
methods,  503  ;  chest.  505  ;  heart, 
507  :   lungs,  508  ;   abdomen.  509 
kidneys  and  capsules,  510;  spleen 
510  ;  "stomach,   510;    liver,   511 
intestines,  511;  pelvis,  512;  head 
512;     brain,    513;     spine,     515 
post-mortem  examination  in  pri- 
vate houses,  516;  preservation  of 
structures,  516 

Postpharyngeal  abscess,  292 

Potain's  tube  for  diluting  blood, 
283  ;  hsemochromometre,  286 

Powdered-wig  deposit  in  urine,  356 

Pregnancy,  hemiplegia  in,  ISl  ; 
convulsions  in,  190  ;  insanity 
d;)ring,  229  ;  dyspnoea  in,  267  ; 
albuminuria  in,  365  ;  leueorrbcea 
during.  407  ;  diagnosis  of,  412 

Presbyopia,  138,  155 

Presystolic  murmurs,  465 

Priapism,  397 

Primary  battery  current,  208 

Primary  induced  current,  209 

Prinkling,  160 

Proglottides  of  tape-worms  (Figs. 
35,  36).  321,  322 

Progressive  locomotor  ataxy  and 
progressive  labio-glosso-laryn- 
ge;il  paralysis,  see  Ataxy  and 
Glosso-labial  paralysis 

Protoplasm,  minute  fragments  in 
blood,  285 


"Prune-juice"  expectoration,  276 

Prurigo,  93.  97;  pruriginous  erup- 
tion (note)    93,  99 

Pruritus,  97,  99 

Psoriasis,  95,  97 

Pseudo-hypertrophie  muscular  pa- 
ralysis," 160 

Ptosis,  129.  135 

Puberty,  mania  of,  229 

Puerile  breathing.  442.  443 

Puerperal  state,  convulsions  in,  190; 
albuminuria  in,  365 

Puerperal  fever  and  erysipelas, 
temperature  in.  74  :  connection 
between.  114;  joint  affections  in 
puerperal  state.  126 

Pulmonary  artery,  embolism  and 
thrombosis  of,  260  ;  aneurism  of, 
a  cause  of  haemoptysis,  277;  visi- 
ble pulsation  in,  455  ;  area  of 
murmurs  connected  with,  470 

Puls.-ition,  audible,  159  :  visible  in 
arteries,  82;  in  episrastrium,  263, 
455;  in  abdomen.  481  ;  from  ab- 
dominal aorta,  263,  455 ;  from 
right  ventricle,  455 ;  at  base  of 
heart,  455 ;  from  auricles  and 
pulmon.-iry  artery,  455  ;  in  vessels 
of  neck,  456;  in  thorax  from 
aneurism,  458,  475 ;  pulsating 
tumor,  475,  477;  see  also  Apex- 
beat 

Pulse,  works  on,  68  ;  frequency  of, 
78;  pulse-rate,  78;  influence  of 
movement,  food,  and  stimulants 
on,  78;  diurnal  range  of  78; 
comparison  with  temperature.  79  ; 
strength  of,  79  ;  ratio  to  respira- 
tion, 79 ;  effect  of  abnormal  di- 
vision of  vessels  on,  SO;  different 
on  two  sides,  SO,  81  ;  not  syn- 
chronous on  two  sides, 80  ;  rhythm 
of,  80  ;  intermission  and  irregu- 
larity of,  80,  263.  264;  signifi- 
cance of,  81  ;  tracing  of,  85  ;  di- 
crotous,  81  ;  tracing  of,  84;  hy- 
perdicrotous  pulse,  tracing  of, 
84;  pulse  of  unfilled  arteries 
(aortic  regurgitation),  81  ;  thrill 
in  pulse,  82 ;  healthy  pulse  (trac- 
ing), 84;  various  diseases  (trac- 
ings), 84,  85;  inequality  on  two 
sides  (tracing),  85  :  senile,  rigid 
artery  (tracing),  85;  pulse,  in 
Bright's  disease  (tracing),  86  ; 
increased  tension,  85  ;  sense  of 
throbbing  in  pulses,  263 

Pulse-wave,  parts  of  (tracing),  83 


538 


INDEX. 


Pupils,  contracted  in  fevers,  45  ; 
dilatation  and  contraction  of,  ]85  ; 
inequality  of,  135,  244  ;  irregu- 
larity of,  lo5  ;  variations  in  size 
of  both,  dilatation  and  contrac- 
tion, 135  ;  sensitiveness  to  light, 
135,  136;  oscillation  of,  137;  ar- 
tificial, 136,  153 

Purging,  see  Diarrhoea 

Purpura,  97,  115 ;  purpura  rheu- 
matica,  127;  hemorrhages  in, 
280 

Purring  tremor,  458 

Pus-casts,  376 

Pus,  in  sputum,  274 ;  profuse  ex- 
pectoration of,  274;  vomited, 
313;  in  motions,  321;  in  the 
urine,  370  ;  pus  corpuscles  (Fig. 
45),  371  ;  test  of  pus  by  liquor 
potassEB,  370  ;  significance  of  pus 
in  urine,  372 

Pustulse,  95  ;  malignant  pustule, 
blood  in,  280 

Pyssraia,  temperature  in,  71  ;  joints 
affected,  126  ;  idiopathic,  127 

Pyolitis,  372 

Pyonephrosis,  372 

Pyrexia,  the  class  pyrexiae,  40; 
general  signs  of  pyrexia,  68,  86  : 
rise  and  duration  of,  73,  75  ;  clini- 
cal significance  of  pyrexia,  88 

Pyromania,  237 

Pyrosis,  314 

Pyuria,  370 

QUETELET,  on  growth  of  infant, 
49 
Quinine,  a  cause  of  tinnitus,  159 
Quickening,  414 

RALES  pulmonary,  445  ;  sonorous 
and  sibilant,  445  ;  bubbling  or 
mucous,  445  ;  crepitant,  446 ; 
friction  rale,  446 

Kanula,  307 

Rashes,  febrile,  88,  97,  105  ;  date  of 
appearance  of,  105 

Eaving,  see  Delirium  and  Mania 

Reaction  of  urine,  353 

Recti,  muscles  of  ej'e,  132,  133,  134 

Rectum,  temperature  taken  in,  70  ; 
paralysis  of,  178;  pains  in,  319; 
abscesses  opening  into,  321;  ex- 
amination of  pelvic  organs  per 
rectum,  417 

Red  blood  corpuscles,  see  Blood 

Reduplication  of  heart's  sounds, 
464 


Reflex  actions  in  paralysis,  171, 
172;  reflex  paralysis,  180;  reflex 
actions  in  paraplegia,  182 

Regions,  anatomical,  in  case-taking, 
55,  56  ;  of  chest,  429  ;  of  abdo- 
men, 478 

Regurgitation  of  food,  314 

Relapses,  effect  of,  on  temperature, 
77 

Relapsing  fever,  occasional  rash  in, 
105,  112;  affection  of  joints  in, 
124  ;  bacterium  in  blood,  285 

Religious  fervor  in  insanity,  229 

Renal  tube-cast  and  epithelium,  see 
Tube-casts  and  Epithelium 

Reporting  of  medical  cases,  53 

Reproductive  system, in  case-taking, 
68  ;    (see  Chapters  xiv  and  xv) 

Residence,  importance  of,  in  case- 
taking,  62 

Resonance  of  voice  in  auscultation, 
448  ;  of  observer's  voice,  448  ;  of 
heart's  sounds,  449 

Respiration,  muscles  of,  involved  in 
general  paralysis,  243  ;  number 
of  respirations  per  minute,  257  : 
as  indicative  .  of  dyspnoea,  258  ; 
sighing,  suspirious,Cheyne- Stokes 
respiration,  267;  ''cerebral"  re- 
spiration in  brain  di.^ease  and 
fevers,  267;  laborious,  258,  267; 
movements  of,  thoracic  and  abdo- 
minal, 435  ;  movements  of  abdo- 
men and  abdominal  organs,  481 

Respiratory  murmur,  variations  in 
health,  442;  weakened,  443 ;  ex- 
aggerated or  puerile,  443  ;  jerky, 
sighing,  443 ;  prolonged  expira- 
tion, 444;  bronchial  or  tubular, 
444  ;  cavernous,  444 

Respiratory  system,  in  ease-taking, 
67  ;  Chapter  ix,  on  disorders  of, 
255;  works  of  reference  on,  255; 
see  also  Chapter  xvi,  parts  1  and 
2 

Retention  of  urine,  178 

Retina,  ophthalmoscopic  examina- 
tion of,  141  ;  hemorrhages,  exu- 
dations, &e.,  142  ;  hypersesthesia 
of,  157  ;  hemorrhages  in,  280 

Retinitis  pigmentosa,  157 

Retraction  of  one  side  of  the  chest, 
433 

Retro-pharyngeal  abscess,  292 

Retroversion  of  uterus,  di.agnosis 
of,  419 

Rheumatic  gout,  rheumatoid  arthri- 
tis, rheumatic  arthritis,  122 


INDEX. 


539 


Rheumatism,  diathesis  of,  41  :  group 
of  allied  diseases,  65  ;  affection 
of  joints  in,  122;  acute  rheuma- 
tism, 123  ;  chronic  rheumatism, 
124  ;  quasi-rheumatic  affections 
in  scarlatina,  124,  126  ;  in  re- 
lapsing fever,  124;  gonorrhoea] 
rheumntism,  124;  as  cause  of 
neuralgia,  1S4;  allied  to  chorea, 
197  ;  electricity  in,  219  ;  cause  of 
insanity,  235 

Rhinoscopy  in  aural  disease,  145  ; 
method,  301  ;  when  called  for, 
301  ;  works  of  reference  on,  302 

Rhonchi,  see  Rales 

Rhythm  of  pulse,  80  ;  of  respiration, 
266  ;  of  respiratory  murmur.  443; 
of  cardiac  murmurs,  465,  472 

Rickets,  physiognomy  of,  41  ;  pre- 
cursory symptoms,  42 ;  Jenner 
on,  42;  cachexy  in,  43 ;  tendency 
to  convulsions  and  laryngismus 
stridulus,  189,  270  ;  chest  in  (Fig. 
66),  432 

Rigidity,  early  and  Inte  in  paraly- 
sis, 170;  plastic  rigidity,  191 

Rigors  in  fever,  44  ;  from  pnssage 
of  catheter,  44  ;  in  jaundice,  335 

Ringworm  (see  Tinea  tricophytina), 
97,  103;   of  nails,  119 

Rise  of  temperature,  manner  of,  73, 
74  ;   in  relapses,  77 

Roberts  (Dr.  Wni.),  on  case-taking, 
66 ;  on  estimation  of  sugar  by 
fermentation,  359  ;  on  estimation 
of  albumen  by  nitric  acid,  363 

Rbtheln,  see  German  measles 

Rosalia,  see  German  measles 

Rose-spots,  112 

Roseola,  93,  97 ;  exanthematica, 
107;  (see  also  German  measles, 
106  and  110) 

Round  worms,  322,  323 

Rubeola  notha,  see  German  measles  ; 
rubeola,  see  Measles 

Running,  cause  of  dyspnoea,  261 

Rupia,  94,  96,  97 

Russel  and  West's  solution  of  hypo- 
bromite  of  soda  for  urea  analysis, 
393 

Rusty  spit  of  pneumonia,  275  ;  ab- 
sence of,  276 

S  =  SCHLIESSUNG=  closing  of 
circuit  (electricity),  218 
Salaam,  convulsions,  172,  193 
Salivation,  307,  330 
Si'.nd  in  urine,  see  Gravel,  Urine,  &c. 


Sanders  (Professor) ,  on  case-staking, 
55  ;  form  recommended  by,  57 

Santorini,  cartilages  of,  in  larynx, 
296 

Sarcina  ventriculi  (Fig.  31),  313; 
in  urine,  causing  turbidity,  355 

Satyriasis,  228 

Scabies,  95,  97  ;  acarusscabiei  (Fig. 
IS),  98 

Scabs,  see  Crusts,  96 

Scales,  95 

Scarlatina  rash,  107;  period  of  in- 
cubation, 106  ;  liability  to  second 
attack,  106  ;  glands  in,  121  ;  joints 
in,  124,  126  ;  cause  of  chorea, 
197;  throat  in,  209;  tongue  in, 
307 

Scarlatina,  albuminuria  in,  365 

Scirrhus,  97 

Sclereme,  339 

Scleroderma,  97 

Scratching  in  skin  eruptions,  99 

Scrivener's  palsy,  see  Writer's 
cramp 

Scrofula(see  also  Struma),  cachexia 
of,  40  ;  group  of  diseases  allied 
to,  64  ;  glands  in,  120 

Sculpture,  and  ideal  proportions, 
33 

Scurvy,  115;  joints  pained  in,  127  ; 
hemorrhages  in,  289 

Scybala,  320 

Seborrhoea,  97 

Second  nerve,  see  Optic  nerve 

Secondary  induced  current,  208 

Sedatives,  use  of,  case  talking,  62  ; 
cause  of  sleeplessness,  202 

Sediments  in  urine,  356 

Semen,  emissions  of,  397;    (see  also 

■  Spermatozoa) 

Senile  decay,  26;  dementia,  245 

Sensation,  common,  150  ;  perver- 
sions of,  160  ;  affected  in  paraly- 
sis, 168;  in  insanity,  225,  238; 
action  of  electricity  on  nerves  of, 
218 

Sense,  organs  of,  examination  and 
disorders  of,  128;  eye,  128;  ear, 
144  ;  nose,  146  ;  taste,  148  ;  touch, 
I.mO;  sense  of  temperature,  153; 
muscular  sense,  153  ;  subjective 
disorders  of  special  senses,  153 

Seventh  nerve,  in  taste,  149  ;  "  pars 
intermedia"  of,  149  ;  testing  of, 
161  ;  portio  mollis,  163 

Sexual  desire  (see  also  Venereal 
excesses,  Masturbation,  &c  ),  in 
paralysis,    182,    397  ;    sexual   ex- 


540 


INDEX. 


cesses  in  paralysis,  182,  397  ;  in 
mnnin,  227 

Shaking  in  paralysis,  170,  171  : 
shnking-palsv,  171 

Shingles,  94 

Shiverings,  in  fever,  44,  Sfi,  89  ; 
from  passage  of  catheter,  44 ; 
absence  of,  in  children,  87 

Sibilant  rales,  445 

Sickness,  see  Vomiting,  308 

Siemens  and  Halske  battery,  207 

Sigliing  respiration,  266,  443 

Sight,  see  Vision 

Siins's  speculum,  422 

Smee's  battery,  207 

Size  of  body,  27 

Skin,  works  of  reference  on,  91  : 
eruptions,  91  ;  diseases  of,  elassi- 
ficatiim,  91  ;  elementary  lesions 
of  skin  (Wiibin  and  Bateman), 
92  ;  secondary  changes  in  skin, 
96;  Buchanan  and  Anderson's 
classification  of  skin  diseases,  97; 
functinnal  affections.  p:irasitic, 
syphilitic,  strumous, .febrile  erup- 
tions, inflammations,  new  forma- 
tions, hemorrhages,  97  ;  consti- 
tutional disturbance  in  skin  dis- 
eases, &c.,  99;  cause  of,  100  ; 
staining,  pigmentation,  and  dis- 
coloration, 115;  syphilitic  erup- 
tions, 117:  sensation  of  skin, 
variations  in,  151,  152,  IfiO,  168  ; 
glazing  of  skin  in  anaesthesia, 
152;    perverted  sensation,  158 

Sleep,  effect  on  pulse,  79  ;  tendency 
to,  in  paralysis,  194;  various 
disorders  of,  201  ;  disturbances 
of  203 :  undue  tendency  to,  203; 
causes  of,  204 

Sleepiness,  undue,  203 

Sleeplessness  and  delirium,  199  ;  in 
mania,  226 

Sleeplessness,  201  ;  with  fever  and 
delirium,  i02  ;  in  intemperance, 
202 

"Slender,"  29 

Smell,  sense  of  tests  for,  146  ;  loss 
of,  from  thickening  in  nose.  147  ; 
from  facial  paralysis,  147  ;  per- 
versions of,  158  ;  of  vomited  mat- 
ter, 313;   of  motions,  324 

Smallpox  rash,  108  ;  diagnosis, 
109;  period  of  incubation,  106; 
liability  to  a  second  attack,  106 

Snellen's  test  types,  139 

Snoring  respiration  in  dyspnoea, 
265  (see  Stertor  in  paralysis,  194) 


"Snuffles,"'  147 

Solium  (see  Tffinia),  323 

Somnambulism,  203 

Sonorous  rales,  445 

Sooty  fluids  vomited,  313 

Sound,  uterine,  care  in  cases  of 
sus:peoted  pregnancy,  4i2;  use 
of,  420 

Spare  habit,  32 

Sparks,  electrization  by,  209 

Spasms  in  limb,  170  ;  in  writing 
177;  of  bladder  and  rectum,  178; 
carpo  pedal,  191  ;  in  legs  and 
limbs,  192;  in  region  of  face  and 
neck,  193  ;  histrionic,  193  ;  tonic 
in  various  parts,  194;  of  degluti- 
tion, 194;  of  glottis,  194,  265, 
269,  272  ;  cardiac  spasm,  264  ;  of 
vocal  cords,  300 

Spatula  for  tongue  depression,  287 

Specific  gravity  of  dropsical  fluids, 
346;  of  urine,  351;  high  and  low 
specific  gravity  of  urine,  352  ; 
siiecific  gravity  beads,  352:  dif- 
ferential density  method  of  esti- 
mating quantity  of  sugar,  359  ; 
estimate  of  solids  in  urine  from 
specific  gravity,  369 

Spectra,  157;  spectral  illusions,  158 

Speculum  auris,  145  ;  vaginal,  use 
of  422 

Speech,  affections  of,  in  par.alysis, 
174  ;  in  idiocy,  174  ;  in  deafness, 
174;  affection  from  state  of 
tongue,  307 

Spermatorrhoea,  397 

Spermatozoa  in  urine  (Fig.  52),  379 

Sphyginograph,  works  on,  68  ;  de- 
scription of  method  of  using,  82; 
sphygmographic  tracing,  parts  of, 
83  ;  various  tracings,  84,  86 

Spinal-accessory  nerve,  164 

Spinal  cord,  disease,  180  ;  causing 
pain  in  back,  205  ;  galvanizing, 
220 

Spine,  hot  sponge  causing  tender- 
ne.es,  205  ;  disease  of,  causing 
jiaralysis,  182;  causing  pain  in 
back.  205  ;  tenderness  to  electri- 
cal currents,  219 

Spirilla  in  blood  in  relapsing  fever, 
285 

Spirits,  use  of,  case-taking,  62  ;  a 
cause  of  cirrhosis  of  liver,  345  ; 
see  also  Stimulants 

Spirochaete  Obermeieri  in  relapsing 
fever,  285 

Spirometer,  468 


INDEX. 


541 


Spit,  see  Expectoration  (273) 

Spittoons,  273 

Splashing  sound  in  auscultation, 
447 

Spleen,  enlarged,  c:tu.^ing  dropsy, 
345  ;  physical  es:imination  of, 
490  :   enlarged  (Fig.  85),  492 

Splenic  fever,  bacterium  in  blood, 
285 

Splenic  leukaemia,  120  ;  hemor- 
rhages in.  281  ;  examination  of 
blood  in,  282  (see  Spleen) 

Spores,  ]03;  sporidia,  104;  in 
mould  (Fig.  64),  379  ;  in  yeast 
(Fig.  55),  380 

Sputum,  section  on,  see  Expectora- 
tion (273) 

Squama,  95 

Squint,  129:   see  Strabismus 

Stains  on  skin,  96 

Staggering,  47,  159,  173 

Staining  of  skin,  1 15 

Starch  granules  in  vomited  matter 
(Fig.  31),  313  ;  in  urine  (Fig. 
56)^381 

Starlings  of  limbs,  227 

Static  electricity,  208 

Stature,  increase  in  infancy,  47 

Status  prjesens,  54 

Stealing,  impulse  to,  237 

Stellar  crystals,  3S5 

Sterno-niastoid,  nerve  supply  of, 
164:   twitching  of,  193 

St  rtor  in  paralysis,  194 

Stethograph,  437 

Steihometer,  437 

Stethoscope,  use  and  forms  of,  440  ; 
differential,  441,  461  ;  Spencer's, 
441 

Stimulants,  hnbituiil  use  of,  impor- 
tance of,  in  e:ise  taking,  61,  62; 
effect  of,  on  pulse,  79  :  cause  of 
deliiiuni,  198;  cause  of  sleepless- 
nes.s,  202 

Stiich,  pleuritic,  263 

SiiJhrer's  battery,  207 

Stokes  (Dr.).  on  myoidema,  34;  on 
Cheyne  Stokes  respiration,  267 

Stomach,  vertigo  from,  200;  see 
Vomiting,  308  :  pain  in,  309  ; 
dilatation,  311,  313;  casts  of  fol- 
licles in  vomited  matter,  314  ; 
acidity  of,  314;  flatulence  in, 
314  ;  physical  examination  of,  495 

Stomatitis,  parasitic,  305  ;  vesicu- 
lar, ult-erative,  gangrenous,  306 

Stool.'!  (see  Motions,  319  ;  and  State 
of  bowels,  316) 

46 


I  "Stout,"  29 

j  Strabismus,  129;  convergent,  di- 
!  vergent,  alternate,  129;  concomi- 
j  tant,  129,  131  ;  paralytic  and 
non-paralytic,  129,  131  ;  connec- 
i  tion  with  hypermetropia,  and 
i  myopia.  131;  clinical  significance 
'  of,  134 
.'  Strachan  (Dr  ),  on  "  play,"  50 

Strangury,  medicines  as  causes  of, 
i      369 

!  "  Strawberry  tongue,"  306 
Strength,  tests  of,  in  limbs,  169 
Stricture,  spasmodic,  of  oesophagus, 
i       194 

;  Stridulous  breathing,  265,  269,  270, 
I       271 
Strophulus,  93,  97 
Struma  (see  also  Scrofula),  cachexia 

of,  40  ;   skin  diseases,  97 
Strychnia  poi.^oning,  193 
Stuttering  in  general   pnralysis,  243 
Stupor,  in  fevers,  46  ;   with  melan- 
choly, 240  ;   see  also  Coma 
Sub  involution  of  uterus,  421 
Subjective  disorders  of  senses,  65 
Subsultus  tendinum,  45 
Siiccussion,  Hippocratic,  in  auscul- 
tation,  447 
Sucking,  refusal    of  breasts   by  in- 
fants in  dyspnoea,  258 
Sudaminn,   in    enteric    fever,    113  ; 

eruption  of,   1 13 
SuflfDcation,    sse    various    sections 

under  Dyspnoea  and  Cough 
Suffusion  of  eyes,  129 
Sug.ir  in  urine.  357  ;   copper  test — 
Trommer"s,  357  ;    Fehling's   and 
Pavy's  solution,  357  :    method   of 
testing,   358  ;   quantitative  deter- 
mination   b}'    copper    test,    358  ; 
fermentation     tes',     359  ;     torula 
test,    359  ;    quantitative    test    by 
fermentation,  359  ;   estimation  by 
specific    gravity,     360  ;      Moore's 
test    with    liquor   potassEe,    360  ; 
bismuth    test,    360  ;    polariscope, 
300 
Suicidal  insanity,  237  ;   importance 
of  ascertaining  suicidal  tendency, 
253 
Sulphur,  rash  from,  102 
Sunstroke,  cause  of  paralysis,  195  ; 
of  insanity,  228,  236;    cause    of 
vomiting,  308 
Super-involution  of  uterus,  421 
Supinator    longus,    testing    of,     in 
lead  palsy,  I  S3 


542 


INDEX. 


Suspiriou?  respiration,  266 

Swallowing,  see  Deglutition 

Sweating,  in  rickets,  42  ;  in  fever, 
44,  86  ;  unilateral,  87 

Swimming,  sense  of,  see  Vertigo, 
200 

Mycosis,  96 

Sympathetic,  affections  of,  135, 
136  ;  galvanizing,  220 

Sj-nchronous,  or  non-synchronous 
pulse,  SO 

Syphilis,  cachexia  of,  43  ;  history 
of,  in  case  taking,  61;  syphilis 
(skin),  97  :  eruptions,  117  ;  con- 
genital, 117;  glands  in,  119; 
bones  and  joints,  127:  of  larynx, 
298  ;  as  cause  of  hemiplegia, 
180  ;  as  cause  of  neuralgia,  185  ; 
convulsions  in,  189  ;  and  insan- 
ity, 233  ;  notched  teeth,  328 

Syphilophobia,  234 

Systems,  physiological,  in  case 
taking,  55;  details  of,  57;  (see 
also  under  Nervous  system,  &c  ) 

TABES  mesenterica,  causing 
dropsy,  343 

Taches  bleuatres,  113 

Tache  cerebral e,  34 

Tactile  sense,  tests  of,  and  distribu- 
tion of,  150,  153 

Tffinise,  various  forms  (Figs.  34,  38), 
322;  T.  mediocanellata"(Fig.  34), 
323  ;  head  of  T.  solium  and  T. 
mediocanellata  (Figs  37,  38), 
323 ;  proglottides  (Figs.  35,  36), 
322 

Tait  (Dr.  Lawson),  on  myoidema,  34 

Tape  worms  (Fig.  34),  322  ;  a  cause 
of  insanity,  336 

Tapping,  abdominal,  importance  of 
emptying  of  bladder  beforehand, 
341  :  e.xamination  of  fluids  re- 
moved by  tapping,  346  :  examina- 
tion of  abdomen  immediately 
after  tapping,  346 

Tar,  rash  from,  102 

Taste,  testing  of,  148;  smell  and 
taste,  147  :  affections  of,  148  ;  in 
general  diseases,  149  :  perversion 
of,  158  ;  seventh  nerve,  162 

Teeth,  326  ;   formula  of  milk  teeth, 

326  ;   disorders  of  first  dentition, 

327  ;  second  dentition,  formula  of 
permanent  teeth,  328;  notched 
(syphilitic)  teelh  (Fig.  39).  328; 
causes  of,  328;  falling  out  of, 
329  ;  grinding  teeth,  329 


Temperaments,  26  ;  "  insane  tem- 
perament," 229,  233 

Temperature  of  body,  68;  works  on, 
68  ;   time   of  day  tor   taking,    71, 

72  ;  normal  and  abnormal  tem- 
peratures, table  of,  72  ;  diurnal 
range  in  hectic,  71  ;  manner  of 
rise    and    duration    of  elevation, 

73  ;  rapid  rise  of,  in  certain  dis- 
eases, 74;  gradual,  74;  decline 
of,  date  and  manner,  75  ;  fall  of, 
fallacies  in  judging,  76  ;  fall  be- 
fore death,  77  ;  in  complications 
and  relapses,  77;  of  convales- 
cents, 77  ;  comparison  with  pulse, 
78  ;  in  enteric  fever  and  menin- 
gitis, 78,  79  ;  very  high  and  very 
low  temperature,  73  ;  hyper-py- 
retic and  collapse  temperatures, 
73 :  diagrams  of,  73  ;  sense  of 
temperature,  152;  galvanism  to 
improve  heat  of  limbs,  221  ;  not 
much  elevated  in  mania,  227,  249 

Tendency,  morbid,  26 

Tendons,  starting  of,  at  wrist,  45 

Tenesmus,  326 

Terrors,  night,  203 

Tetanic  contraction  (electricity), 
217 

Tetanus,  193 

Tetany,  192 

Thallus,  104 

Thermic  effects  of  electricity,  209 

Thermometer,  clinical,  68 

"  Thin,"  29 

Third  nerve,  paralysis  of,  134,  135, 
136  ;   testing  of,  161 

Thirst,  304 

Thorax,  see  Chest 

Thread  worms  (Fig.  32),  322 

Thrill,  vocal,  448;  cardiac,  458; 
aneurismal,  475 

Throat,  irritation  and  disease  of, 
causing  cough,  270  ;  catarrh  of, 
288  ;  in  scarlatina,  289  ;  in  diph- 
theria, 289  ;  ulceration  in,  290  ; 
phlegmonous  inflammation,  290  ; 
tonsillitis,  290 ;  syphilitic  affec- 
tion of,  291  ;  destruction  of  tis- 
sue, 291;  retropharyngeal  ab- 
scess, 292  ;  books  of  reference  on, 
.302 

Thrombosis  of  cerebral  vessels  in 
hemiplegia,  181  ;  and  in  chorea, 
197  ;   of  portal  vein,  344 

Thrush,  see  Muguet 

Thudicum  on  analysis  of  renal  cal- 
culi, 388 


INDEX. 


543 


Thumbs,  inversion  of,  192 

Thyroid,  fulness  of,  129 

Tie  (see  neuralgia  of  fifth  nerve, 
184,  161)  ;   convulsive  tic,  193 

Tinea  favosa,  97,  105  ;  tricophytina 
(circinata,  tonsurans  sycosis),  97, 
103  (Fig.  21),  104;  versicolor, 
97  ;  decalvans,  97 

Tingling,  160 

Tinnitus  aurium,  158;  in  paralysis, 
194 

Tobacco,  use  of,  importance  of,  in 
case  taking,  61 

Tongue,  in  fever,  45  (see  also  Taste, 
148)  :  tactile  sense  of,  149;  tem- 
perature under,  70  ;  nervous  sup- 
ply of  Hngualis,  163;  of  extrinsic 
muscles  of,  164;  paralysis,  164; 
quivering  of,  171  ;  ulcer  on  fre- 
nuiu  in  pertussis,  270  ;  tongue- 
depressor,  287  ;  state  of,  section 
on,  305;  infl;imm:ition  of,  307; 
hardness  and  nodulation,  307 ; 
pallor,  lividity,  coldness,  ecchy- 
mosis,  307;  fur  or  coating  on,  305; 
white  patches  of  muguet,  305  : 
discoloration  of,  305  ;  dryness, 
306  ;  cracks  and  hacks,  306  ;  red 
raw  tongue,  306  ;  desquamation 
of  epithelium,  306  ;  strawberry 
tongue,  306  ;  enlarged  pnpillse, 
306;  blisters,  aphthae  on,  307: 
swollen  aspect  of,  307  ;  swellings 
under,  307 

Tonic  convulsion,  187  ;  spasms,  193 

Tonsils,  catarrh  of,  288;  tonsillitis, 
290  ;  chronic  inflammation,  291 

Tophi,  121 

Torticollis,  see  Wry-neck 

Torula  cerevesise  in  vomited  mat- 
ters, 313  ;  in  diabetic  urine,  359 

Torula  in  urine  (Fig.  55),  380 

Touch,  see  Tactile  sense,  150 

Trachea,  affections  of,  giving  rise 
to  cough,  270,  271 ;  foreign  bodies 
in,  272 

Tracheal  respiration,  444 

Trance,  mesmeric,  195 

Trapezius,  nerve  supply,  163  ; 
twitching  of,  193 

Trapp's  formula  for  estimating 
solids  in  urine,  359 

Tremors,  in  paralysis,  170,  172  :  in 
delirium,  199  :  in  general  paraly- 
sis, 243  ;  cardiac  tremor,  purring 
tremor,  493 

Tricophyton,  tonsurans  (Fig.  21), 
104 


Tricuspid  murmur,  area  of,  471 

Trifacial,  161 

Trigeminal,  161 

Trismus,  193 

Trochlearis  (nerve),  161 

Trommer"s  test  for  sugar,  357 

Tube-casts  (renal),  significance  of, 
in  bloody  urine,  319  ;  in  purulent 
urine,  371  ;  how  to  examine  for, 
372  ;  various  kinds  of  373  ;  hya- 
line, waxj',  epithelial,  granular, 
fatty  (Figs.  46,  48),  37-3,  375; 
blood-casts,  pus-easts,  396  :  sig- 
nificance of  tube  casts  of  various 
kinds,  376  ;  absence  of  casts  in 
some  cases  of  albuminuria,  376 

Tubercles,  in  choroid,  142 

Tubercula,  96 

Tubular  respiration,  444 

Tumors,  of  brain,  cause  of  paraly- 
sis, 181  ;  abdominal,  causing 
dropsy,  &c.,  341,  346  ;  in  larynx, 
298  ;  "(syphilitic  in  larynx,  298)  ; 
uterine,  421;  pulsating  tumor, 
475  ;  localities  of  abdominal  tu- 
mors, 501  ;  see  various  organs. 
Liver,  Spleen,  &c. 

Tuning  fork,  test  of  hearing,  144 

Twitchings  of  muscles  of  face  and 
neck,  193  ;  twitching  or  choreic 
movements,  197 

Tympanites,  315,  496 

Tympanum,  membrana  ruptured, 
145  ;  state  of,  145  ;  suppuration 
in,  146 

Types,  in  testing  vision,  139 

Typhoid,  meaning  of  word,  45  ;  ty- 
phoid delirium,  45;  (typhoid 
fever,  see  Enteric) 

Tj'phomania,  45 

Typhus  fever,  period  of  incubation, 
106  ;  liability  to  second  attack, 
106  ;  rash,  111  :  as  a  cause  of  in- 
sanity, 236  ;  mistaken  for  mania, 
250 

Tyrosine  in  urine,  386,  387 

ULCER,  on  frenum  linguae  in  per- 
tussis, 270 
Ulcerations    (in    skin),    96,    97;   of 

throat    in    scarlatina,     289 ;     in 

throat  of  various  kinds,  290 
Umbilical  region  and  contents,  478  ; 

tumors  in,  501 
Umbilicus,    position    and   color   of, 

480 
Unconsciousness  in    paralysis,  167, 

194 ;    in   fits,    188  ;    in    hysteria, 


544 


INDEX. 


191  ;  causes  of,  195  ;  see  also 
Coma 

Unilateral  convulsions,  170  ;  in 
aphasia,  171  j  see  also  Hemi- 
plegia 

Unsteadiness  in  paralysis,  170; 
affecting  writing,   177 

Urates  of^  soda,  in  joints,  126  ; 
urates  in  urine,  35B  ;  precipita- 
tion of  urates  by  nitric  acid — 
fallacy,  362;  deposits  in  urine, 
383  (Figs.  58,  69),  383 

UrsEuiia,  coma  in,  195  ;  convulsions, 
189,  190;  sleepiness  in,  204; 
danger  of  opium  in,  204  ;  head- 
ache in,  205 

Urea,  detection  of,  in  fluids  removed 
by  tapping,  347  ;  nitrate  of  urea 
on  adding  nitric  acid  to  urine, 
363  ;  estimation  of  quantity,  390; 
Liebig's  metiiod,  390  ;  method 
by  hypobromite  of  soda  solution, 
392 

Ureter,  epithelium  from,  377 

Urethra,  pain  in,  395,  410  ;  dis- 
cb;irges  from,  397 

Uric  acid  in  blood,  125  ;  in  urine  as 
gravel,  356  ;  precipitation  of,  by 
nitrii;  acid  in  urine,  362  ;  deposits 
in  urine,  380  (Fig.  57),  382 

Urinary  system,  in  case-taking,  58; 
Chapter  xiii  ,  on  urine  and  uri- 
nary symptoms,  349  ;  see  Urine 
for  details 

Urine,  temperature  taken  of,  70  ; 
retention  and  incontinence  of, 
from  paralysis,  178  ;  passing  urine 
in  bed  at  nights,  179;  filaria 
sanguinis  hominis  in  chyluria, 
285  ;  jaundiced,  332  ;  detection 
of,  in  abdominal  fluids,  346  ;  ex- 
amination of  urine  and  urinary 
symptoms  (Chapter  xiii  )  ;  works 
of  reference  on.  349  ;  routine  ex- 
amination of,  349  ;  samples  to  be 
selected,  350  ;  quantity  passed, 
361;  specific  gravity,  351  ;  reac- 
tion, 353  ;  acid  fermentation  of, 
353  ;  alkalinity  from  decomposi- 
tion, 353  ;  obvious  characteristics 
and  naked  eye  appearances,  354  ; 
color,  clearness,  364  ;  white,  355  ; 
milky,  365  ;  turning  thick,  855  ; 
resembling  porter,  355  ;  turbid 
and  smoky,  355  ;  blood  color, 
355  ;  very  red,  pale,  and  black, 
365  ;  blue,  355  ;  bad  smell,  355  ; 
gas  with  urine,  356  ;  shreds  with, 


356  ;  gravel  and  sediments,  356  ; 
glairy  mutter  in  leucorrhosa,  356  ; 
coagulation  from  chyle,  356  ; 
sugar  in  urine.  357  ;  copper  test, 
Trommer's,  357  ;  Fehling's  and 
Pavy's  solution,  367  ;  quantity  of 
sugar  by  copper  test,  358  ;  by 
fermentation  test,  359  ;  torula 
test  for  sugar,  369  ;  quantity 
estimated  hy  fermentation,  359  ; 
^y  sp-  gr.,  369  ;  Moore's  test  for 
sugar,  360  ;  bismuth  test  for 
sugar,  360  ;  polariscope,  360  ;  al- 
buminuria, 360  ;  tests  for  albu- 
men, 360  ;  test  by  hent,  361  ;  by 
nitric  acid  in  cold,  362  ;  quanti- 
tative   estimation    of    albumen, 

363  ;   significance  of  albuminuria, 

364  ;  blood  in  urine,  367  ;  blood 
corpuscles  (Fig.  44),  367  ;  guaiac 
test  for  blood,  368  ;  significance 
of  hsematuria,  369  ;  pus  in  urine 
370;  pus  corpuscles  (Fig.  45), 
370  ;  liquor  potassa3  test  for  pus, 
370  ;  significance  of  pyuria,  372; 
renal  tube-casts,  373 ;  how 
searched  for,  373  ;  various  kinds 
of,  373-375  (Fig.  46-48)  ;  sig- 
nificance of  casts,  376  ;  epithe- 
lium in  urine,  377;  renal,  vesi- 
cal, &c.  (Figs  49  and  50),  377; 
vaginal  epithelium  (Fig.  61),  378  ; 
speiinatoziia  (Fig.  52),  379  ; 
mould  (Fig.  64),  379  ;  vibriones 
(Fig.  53),  379  ;  fungi,  379  ;  yeast 
fungus  (Fig.  65),  380;  foreign 
matters  in,  379  (Fig.  56),  381; 
crystalline,  amorphous  deposits, 
380  ;  signifii-ance  of  these,  386  ; 
uric  acid  deposits,  380  (Fig.  57)  ; 
382,  386  ;  urates  or  lithates  (Figs. 
58,  69),  383,  386;  pho.^^phates, 
384  (Figs.  60,  61),  385,  387  :  oxa- 
lates (Fig.  62),  385,  386;  analy- 
sis of  calculi,  387  ;  bile,  389  ; 
biliary  acids,  389  ;  chlorides, 
390  ;  estimation  of  urea,  390 ; 
complaints  as  to  urinary  symp- 
toms, 394 

Urinometer,  352 

Uro  hsematine,  362 

Urticaria,  93  ;  fictitious,  93,  97 

Uterus,  disease  of,  a  cause  of  in- 
sanity, 229  ;  defect  of,  a  cause  of 
amenorrhoea,  401;  hemorrhage 
from,  403;  disorders  of,  causing 
dysmenorrhoea,  405;  gravid,  412, 
413;  examinations  per  vaginam. 


INDEX. 


545 


4]3  ;  points  nttended  to  in  exam- 
ining, 415  ;  flexions,  418  ;  state  of 
cervix,  418  ;  displacements,  419, 
420;  use  of  sound,  420  ;  constric- 
tion of  cervix,  420  ;  depth  of, 
420;  connections  of  tumors,  421  ; 
subinvolution,  421  ;  hyper-invo- 
lution, 421  ;  examination  by  spe- 
culum, 422  ;  pelvic  inflamma- 
tions, perimetritis,  Ac,  423  ;  bte- 
matocele,  426  ;  carcinoma,  426  ; 
fetid  discharge  from,  427,  428; 
see  also  Menstruation,  Dysmen- 
orrhoea,  &c. 
Uvula,  paralysis  of,  161,  162,  163; 
elongated,  causing  cough,  271  ; 
examination  of,  changes  in,  288; 
cauirrh  involving,  288 

VD.  ^Ventricular-diastolic 
.     V.  S.  =  Ventricular-systolic 

Vaccinia,  94 

Vagabondism  us,  116 

Vagina,  temperature  taken  in,  70; 
as  compared  with  axilla  in  col- 
lapse, 77  ;  scaly  epithelium  from, 
in  urine  {Fig.  51),  378 

Vaginal  examinations,  415  ;  in 
pregnancy,  413;  when  such  de- 
manded, 414;  mode  of,  415  ;  in- 
dic.itions  from,  417 

Vaginismus,  417 

Valsalva's  method  of  inflating  ear, 
145 

Valvular  murmurs,  rhythm  of,  465; 
area  of,  469  ;  tabular  view  of,  473 

Vapors,  irritating,  causing  cough, 
271 

Varicella,  93,  108  ;  period  of  incu- 
bation, 103;  liability  of  second 
attack,  106 

Vnriola,  95,  108 

Varix,  97 

Vena  portaa,  see  Portal  vein 

Venereal  disease,  history  of,  in  pa- 
tients, 61 

Veneral  excesses  (see  also  Sexual 
desire.  Masturbation,  &c.),  his- 
tory of,  in  patient,  63  ;  cause  of 
paralysis,  182,  396;  and  insanity, 
229  ;  a  cause  of  general  paralyses, 
244  :  cause  of  impotence,  396 

Ventricle  of  larynx,  296 

Ventricular  diastolic  murmur  (Fig. 
77),  467 

Ventricular-systolic  murmur  (Fig. 
76),  467 

Verruca,  96,  97 


Vertebrifi,  abscess  in  front  of,  point- 
ing in  throat,  292 

Vertigo,  monocular,  154;  in  ocular 
paralysis,  154  ;  in  aural  disease, 
146,  168;  in  paralysis,  194;  va- 
rieties and  causes  of  vertigo,  200  ; 
stomachal,  201  ;  warning  of  par- 
alysis, 201 

Vesication  in  erysipelas,  114 

Vcsieulse,  94 

Vesicular  murmur,  see  Respiratory 
murmur 

Vitiligo,  96,  97,  117 

Vibices,  115 

Vibriones  in  urine  (Fig.  53),  379 

Vicarious  menstruation,  276 

Vienna  test  for  pus  in  urine  (liquor 
potassse),  370 

Vi.<cera,  thoracic  in  situ  (Fig.  81), 
470  ;   abdominal  (Fig.  83).  479 

Vision,  aeuteness  of,  13S  :  field  of 
vision,  139:  subjective  disorders 
of,  153;  double,  154;  erroneous 
estimate  of  position  of  objects, 
154;  forward  displacement  of 
image,  154;  confusion  of  lines 
in  reading.  155;  motes,  155; 
heraiopia,  156;  flashes  of  light 
and  color,  156  ;  color-blindness, 
157;  yellow  vision,  157;  dimness 
of,  159;  importance  of  sight  in 
balancing  in  iitaxy,  174 

Vitreous,  opacities  in,   156 

Vocal  Cords,  examination  of,  295  ; 
paralysis  and  spasm  of,  299  ; 
vocal  resonance,  447 

Voice,  alterations  of,  in  laryngeal 
disease,  299  (see  also  Speech, 
Hoarseness);  resonance  and  fre- 
mitus, 447;   alterations  in,  448 

"  Voices"  heard  by  the  insane, 
238,  241 

Volta-dynamie  instruments,  207 

Voltaic  battery  or  pile,  207 

Vomiting,  character  of  vomited 
matter.  312  ;  of  blood,  312;  fecal, 
312;  coffee  grounds,  313;  of  bile, 
pus,  worms,  &c.,  313;  microsco- 
pic examination  of  vomited  mat- 
ters, 313  ;  sarcinEe  (Fig.  31),  313; 
fermentation,  odor  of,  312;  vari- 
ous causes  of,  308;  preliminary 
symptoms,  308  ;  influence  of  pos- 
ture on,  309  ;  pains,  &c  ,  associ- 
ated with.  309  ;  pain  in  stomach 
with,  309;  "causeless,"  309; 
vomiting  and  headache,  310;  pain 
in     back    and     vomiting,     310  ; 


546 


INDEX, 


disorder  of  bowels  witli  vomiting, 
310  ;  from  iriitntion  of  fauces, 
310;  with  coughing,  310;  from 
uterine  disorder  and  pregnancy, 
310  (see  also  chapter  x v.,  ;ot5.vm«); 
from  renal  disease,  311  ;  from 
biliary  disorder,  311  ;  oesopha- 
geal, 311  ;  vomited  matters,  311  ; 
quantity  vomited,  311 

WALKING,  manner  of,  in  gene- 
ral paralysis,  47  ;  in  hemiple- 
gia, 47  ;  in  paraplegia,  47  ;  in 
locomotor  ataxy,  47;  in  drunken- 
ness, 47;  in  apoplexy  and  cere- 
bellar disease,  48  ;  unsteadiness, 
tremor  in,  171;  hurrying  forward, 
172;  testing  of,  172;  deficiency 
from  idiocy,  172;  lateness  in 
rickets,  172;  in  various  forms  of 
paralysis  and  ataxy,  173  ;  relation 
of  sight  to,  174;  affected  in  gen- 
eral paralysis,  242 

Wnrt,  96 

Water-brash,  314 

Watery  discharge  from  ears,  145  ; 
from  womb,  408 

Wavy  respiration,  443 

Wax  in  ear,  145 

Waxy  tube-easts  (Fig.  46),  374 

Weber's  test  of  sensation,  150  ; 
cautions  in  applying,  151  ;  table 
of  relative  sensibility,  152 

Weeping,    in    paraljsis,    168 ; 
Emotions);  in  hysteria,   190. 

Weight,  sense  of,  153 

Weight  of  body,   27  ;   loss    of, 
variations  from  time  to  time 
according  to  height   (table), 
excessive   and  defective,   31 ;    in- 
crease in  infancy,  49 

Wetting  the  bed,  1*79 

Wheals,  93 

Wheezing  sounds  in  dyspnoea,  265  ; 
in  auscultation,  445 

Whirling,  sense  of,   199 

Whisper,  voice  reduced  to,  299 


(see 


Whistling  sounds  in  dyspnoea,  265  ; 

in  auscultation,  445 
White  patches  of  skin,  117 
White  bloodoorpuscles,  see  Blood; 

white  blood,  see  Leukfsmia 
AVhite    discharge    ("  whites"),    see 

Leucorrhoea 
Whooping  cough,  269  ;  resemblance 

of    bronchial    phthisis    to,   271; 

vomiting  in,  3  10 
Willan  and  Bateman,  93 
"Wiry,"  29 
Womb,     see    Uterus;    bemorrhage 

from,  see  Metrorrhagia 
Women,  disorders  peculiar  to  (chap- 
ter XV.),  399 
Worms,  vomited,  313  ;   in  motions. 

322  (Figs.  32,  38) 
Wrisberg,  cartilages  of,  in  larynx, 

296 
Wrist,  spasm  of,  in  infancy,  192 
"Wrist-drop,"  48,  183 
Writer's  cramp,  177 
Writing,  power  of,  in  aphasia,  176  ; 

tests  by,  in  aphasia,  176  ;  power 

of    writing    affected    in    various 

ways,    177  ;  cramp  in,   177  ;    test 

by,  in  insanity,  244,  952 
Wry-neck,  193 

XANTHOPSIA,  157 
Xeroderma,  96 

\7  AWNING-,automatie  movements 
l       during,  in  hemiplegia,  L70 
Yeast,  see  Torula  eerevesise  ;  yeasty 
vomited   matters,    313  ;    test   for 
sugar  by,  358,  359. 
Yellowness  of  eye,  189 

Z=ZUCKUNa,  contraction  of 
muscle  (electricity),  218 
Ziemssens's  motor  points  (electri- 
city), 211  (Figs.  23-28)  ;  method 
of  exciting  phrenic  nerve  electri- 
cally, 221 


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O-    MATIONS  OF  THE  RECTUM   AND    ANUS.     With   remarks    on 

Habitual  Constipation.     Second  American  from,  the  fourth  London 

edition,  with  illustrations.    1  vol.  8vo.  of  about  300  pp.    Cloth,  $3  25. 


2  HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

ASHHTJRST  (JOHN,  Jr.)  THE  PRINCIPLES  AND  PRACTICE  OF 
SURGERY.  FOR  THE  USE  OF  STUDENTS  AND  PRACTI- 
TIONERS. Second  and  revised  edition.  In  1  large  8vo.  vol.  of 
over  1000  pages,  containing  542  wood-cuts.  Cloth,  $6  00;  leather, 
$7  00.      {Now  ready .) 

ATTFIELD  (JOHN).  CHEMISTRY;  GENERAL,  MEDICAL,  AND 
PHARMACEUTICAL.  Eighth  edition,  revised  by  the  author.  In 
1  vol.  12mo.  of  700  pages,  with  87  illustrations.  Cloth,  $2.50;  leather, 
$3.00.     {Noiv  ready.) 

ASHWELL  (SAMUEL).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OP  WOMEN.  Third  American  from  the  third  London  edi- 
tion. In  one  Svo.  vol.  of  528  pnges.  Cloth,  S3  50. 
BROWNE  (LENNOX).  THE  THROAT  AND  ITS  DISEASES.  With 
one  hundred  illustrations  in  color  and  fifty  wood-cuts.  In  one  hand- 
some imp.  Svo.  vol.,  cloth,  $5.00.  (Just  issued.) 
BROWNE  (EDGAR  A.)  HOW  TO  USE  THE  OPHTHALMOSCOPE. 
Elementary  instruction  in  Ophthalmoscopy  for  the  Use  of  Students. 
In  one  small  12mo.  vol  ,  many  illust.      Cloth,  $1.      {Just  issued.) 

BLOXAM  (C.  L.)  CHEMISTRY,  INORGANIC  AND  ORGANIC. 
With  Experiments.  In  one  handsome  octavo  volume  of  700  pages, 
with  300  illustrations.    Cloth,  $4  00  ;  leather,  $5  00. 

BRINTON  (WILLIAM).    LECTURES  ON  THE  DISEASES  OF  THE 
STOMACH.    From  the  second  London  ed.    1vol.  Svo.    Cloth,  $3  25. 
BASHAM  (W.   R.)     RENAL  DISEASES;  A  CLINICAL  GUIDE  TO 
THEIR   DIAGNOSIS   AND   TREATMENT.       With   illustrations. 
1  vol.  12mo.     Cloth,  $2  00. 

BUMSTEAD  (F.  J.)  THE  PATHOLOGY  AND  TREATMENT  OF 
VENEREAL  DISEASES.  Fourth  edition,  revised  and  enlarged, 
with  the  co-operation  of  R.  W.  Taylor,  M.D.  1  vol.  8vo.,  of  835 
pages,  with  138  illustrations.  Cloth,  $4  75  ;  leather,  $5  75.  {Just 
ready.) 
AND  CTJLLERIER'S  ATLAS  OF  VENEREAL.  See"CuLLERiER." 

BARLOW  (GEORGE  H.)  A  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.     1  vol.  Svo. ,  of  over  60    pages.     Cloth,  $2  50. 

BRISTOWE  (JOHN  SYER).  A  TREATISE  OP  THE  PRACTICE  OF 
MEDICINE.  Second  American  edition,  revised  by  the  author. 
Edited  with  additions  by  James  H.  Hutchinson,  M.D.  In  one 
handsome  Svo.  volume  of  nearly  1200  pages.  Cloth,  $5  00;  lea- 
ther, $6  00.  {Just  ready.) 
BOWMAN  (JOHN  E.;  INTRODUCTION  TO  PRACTICAL  CHEM- 
ISTRY, INCLUDING  ANALYSIS.  Si.xth  American,  from  the  si.xth 
London  edition,  with  numerous  illustrations.  1  vol.  12mo.  of  350 
pages.     Cloth,  $2  25. 

BELLAMY'S  MANUAL  OF  SURGICAL  ANATOMY.     With  numerous 
illustrations.    In  one  royal  ]  2mo.  vol.    Cloth,  $2  25.    {Lately issued.) 
BAIRD  (ROBERT).    IMPRESSIONS  AND  EXPERIENCES  OF  THE 
WEST  INDIES.     1  vol.  royal  12mo.     Cloth,  75  cents. 
"DRYANT  (THOMAS).    THE  PRACTICE  OF  SURGERY.    Second  Am. 
•*^     from  Second  English  Edition.     In  one  handsome  Svo.  vol.  of  over 
1000  pp.,  with672  illust.    Cloth,  $6.00;  leather,  $7.00.    {Now  ready.) 

BARNES  (ROBERT).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  WOMEN.  Second  American,  from  Second  English  Edn. 
In  one  handsome  Svo.  vol.  of  about  784  pages,  with  181  illustrations, 
cloth,  $4  50;  leather,  $5  50.     {Jtist  issued.) 


HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS.  3 

•pARNES  (FANCOURT).     A  MANUAL  OP  MIDWIFERY  FOR  MID- 
■'-'     WIVES.     In  one  neat  royal    12mo.  vol.,  with  numerous  illustra- 
tions.    Cloth,  $125.      {Now  Ready.) 

BURNETT  (CHARLES  H.)  THE  EAR:  ITS  ANATOMY.  PHYSI- 
OLOGY, AND  DISEASES.  A  Prnctical  Treatise  for  the  Use  of 
Students  and  Practitir  ners.  In  one  handsome  8vo  vol.  of  615  pp., 
■with  87  illustrations.  Cloth  $4  50;  leather,  $5  50. 
■pLANDFOED  C?.  FIELDING).  INSANITY  AND  ITS  TREATMENT. 
-'-'  With  an  Appendi.x  of  the  laws  in  force  in  the  United  States  on  ^he 
Confinement  of  the  Insane,  by  Dr.  Isaac  Ray.  In  one  handsome  8vo. 
vol.,  of  471  pages.     Cloth,  $3  25. 

pHAECOT  (J.  M.)    LECTURES  ON  THE  NERVOUS  SYSTEM.    1  vol. 
^     Svo.  of  288  pages,  with  illustrations.     Cloth,  $1  75.     (Now  ready.) 

CLASSEN'S  QUANTITATIVE  ANALYSIS.  Translated  by  Edgar  F. 
Smith,  Ph.D.  In  one  handsome  12mo.  vol.  cloth,  $2.  {J^ist  issued.) 
CARTER  (R  BEUDENELL).  A  PRACTICAL  TREATISE  ON  DIS- 
EASES OF  THE  EYE.  With  additions  and  test-types,  by  John 
Green,  M.D.  In  one  handsome  Svo.  vol.  of  about  500  pages,  with 
124  illustrations.     Cloth,  $.S  75. 

pHAMBERS  (T.  K.)       A  MANUAL   OF    DIET   IN    HEALTH    AND 
'-'     DISEASE.     In  one  handsome  octavo  volume  of  310  pages.     Cloth, 

$2  75. 

GQOPEE  (B.  B.)  LECTURES  ON  THE  PRINCIPLES  AND  PRACTICE 
OF  SURGERY.     In  one  large  Svo.  vol.  of  750  pages.     Cloth,  «2  00. 

pAEPENTER  (WM.  B.)     PRINCIPLES  OF  HUMAN  PHYSIOLOGY. 
^     A  new  American,  from  the  Eighth  English  Edition.     In  one  large 

vol.  Svo.,  of  1083  pages.     With   373  illustrations.      Cloth,  $5  50; 

leather,  raised  bands,  S6  50.      (Lately  issued.) 

PRIZE  ESSAY  ON  THE  USE  OF  ALCOHOLIC  LIQUORS  IN 

HEALTH  AND  DISEASE.     New  Edition,  with  a  Preface  by  D.  F. 
Condie,  M.D.     1  vol.  12mo.  of  178  pages.    Cloth,  60  cents. 

CLELAND  (JOHN).  A  DIRECTORY  FOR  THE  DISSECTION  OF 
THE  HUMAN  BODY.     In  one  small  royal  12mo.  vol.    Cloth,  $1  25. 

pENTUEY  OF  AMERICAN  MEDICINE.— A  History  of  Medicine  in 
^     America,  1776-1876.     In  one  royal  12mo.  vol.  of  366  pages.    Cloth 
$2  25. 

CHURCHILL  (FLEETWOOD).  ON  THE  THEORY  AND  PRACTICE 
OF  MIDWIFERY.  With  notes  and  additions  by  D.  Francis  Condie, 
M.D.  With  about  200  illustrations.  In  one  handsome  Svo.  vol.  of 
nearly  700  pages.     Cloth,  $4;  leather,  $5. 

ESSAYS  ON  THE  PUERPERAL  FEVER,  AND  OTHER  DIS- 
EASES PECULIAR  TO  WOMEN.  In  one  neat  octavo  vol.  of 
about  450  pages.     Cloth,  $2  50. 

pHADWICK  (JAMES  R.)     A  MANUAL  OF  THE  DISEASES  PECU- 
^     LIAR  TO  WOMEN.     In  one  neat  royal  12mo.  vol.     With  illustra- 
tions.     {Preparing.) 

pORNIL  (V.),  AND  EANVIEE  (L.).     MANUAL  OP  PATHOLOGICAL 
^     HISTOLOG?.     Translated,    with    Notes   and  Additions,   by   E.   0. 
Shakespeare  and  Henry  C.  Simes,  M  D.     In  one  vol.  Svo  of  784  pp. , 
with  360  illus.     Cloth,  $5  50  ;  leather,  $6  50.      {Jiist  ready.) 

pDNDIE  (D.  FRANCIS).     A  PRACTICAL  TREATISE  ON  THE  DIS- 

^     EASES  OF  CHILDREN.     Sixth  edition,  revised  and  enlarged.     In 

one  large  Svo.  vol.  of  800  pages.     Cloth,  %b  25  ;  leather,  $6  25. 


4  HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

CLOWES  (FE^NK).  AN  ELEMENTARY  TREATISE  ON  PRAC- 
TICAL CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANA- 
LYSIS. From  the  Second  Entc.  Ed.  In  one  12aio.  vol.  Cioth,  $2  50. 
OULLERIER  (A.)  AN  ATLAS  OF  VENEREAL  DISEASES.  Trans- 
lated and  edited  by  Frbkman  J.  Bumstead,  M.D.  A  large  imperial 
quarto  volume,  with  26  plates  containing  about  150  figures,  beauti- 
fully colored,  many  of  them  the  size  of  life.  In  one  vol.,  strongly 
bound  in  cloth,  §17. 

Same  work,  in  five  parts,  paper  covers,  for  mailing,  $.3  per  part. 

pYCLOPEDIA  OF  PEACTICAL  MEDICINE.     By  Dunglison,  Forbes, 
^     Tweedie,  and  Conolly.     In  four  large  super-royal  octavo  volumes,  of 
3254  double-columned  pages,  leather,  raised  bands,  $15.    Cloth,  $1 1 . 
riHRISTlSON  &  GRIFFITH'S  DISPENSATORY.     1  vol.,  cloth,  $4. 

G.\MPBELL'S  LIVES  OF  LORDS  KENYON,  ELLENBOROUGH,  AND 
TENTERDEN.  Being  the  third  volume  of  "  Campbell's  Lives  of 
the  Chief  Justices  of  England."  In  one  crown  octavo  V(j1.  Cloth,  $2. 
■n\LTON  (J.  C.)  A  TREATISE  ON  HUMAN  PHYSIOLOGY.  Sixth 
-'-'  edition,  thoroughly  revised,  and  greatly  enlarged  and  improved,  with 
316  illustrations.  In  one  very  handsome  Svo.  vol.  of  830  pp. 
Cloth,  $5  50;   leather,  $6  60. 

D"7NCAN  (J  MATTHEWS).  CLINICAL  LECTURES  ON  THE  DIS- 
EASES OF  WO.MBN.  Delivered  in  St.  Bartholomew's  Hospital. 
In  one  neat  Svo.  volume.  Cloth,  $1  50.  {Jmt  ready.) 
TJWIS  (F.  a.)  LECTURES  ON  CLINICAL  MEDICINE.  Second 
-'-'  edition,  revised  and  enlarged.  In  one  12mo.  vol.  Cloth,  $1  75. 
"nON  QUIXOTE  DE  LA  MANCHA.  Illustrated  edition.  In  two  hand- 
'-'  some  vols,  crown  Svo.  Cioth,  S2  60  ;  half  morocco,  $3  70. 
DsWEES  (W.  P.)  A  TREATISE  ON  THE  DISEASES  OF  FEMALES. 
AVith  illustrations.     In  one  Svo.  vol.  of  536  pages.     Cloth,  $3. 

D-aUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF  MO- 
DERN SURGERY.  A  revised  American,  from  the  eighth  London 
edition.  Illustrated  with  432  wood  engravings.  In  one  Svo.  vol. 
of  nearly  700  pages.     Cloth,  $4;  leather,  $5. 

DUNGLISON  (ROBLEY),  MEDICAL  LEXICON;  a  Dictionary  of 
Medical  Science.  Containing  a  concise  explanation  of  the  various 
subjects  and  terras  of  Anatomy,  Physiology,  Pathology,  Hygiene, 
Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence,  and  Dentistry.  Notices  of  Climate  and  of  Mineral 
Waters;  Formulas  for  Officinal,  Empirical,  and  Dietetic  Preparations, 
with  the  aceentviation  and  Etymology  of  the  Terms,  and  the  French 
and  other  Synonymes.  In  one  very  large  royal  Svo.  vol.  New  edi- 
tion. Cloth,  $6  50  ;  leather,  $7  50. 
DE  LA  BECHE'S  GEOLOGICAL  OBSERVER.  In  one  large  Svo.  vol. 
of  700  pages,  with  300  illustrations.  Cloth,  $4. 
D\NA  (JAMES  D.)  THE  STRUCTURE  AND  CLASSIFICATION  OF 
ZOOPHYTES.  With  illust.  on  wood.  In  one  imp.  4to.  vol.  Cloth,  $4. 
ELLIS  (GEORGE  VINER).  DEMONSTRATIONS  IN  ANATOMY. 
Being  a  Guide  to  the  Knowledge  of  the  Humau  Body  by  Dissection. 
From  the  eighth  and  revised  English  edition.  Illustrated  by  24.8 
engravings  on  wood.  In  one  very  hand.-ome  Svo.  vol.  of  over  700  pp. 
Cloth.  $4  25;   leather,  $5  25.      (Noiv  Ready.) 

EMMET  (THOMAS  ADDIS).  THE  PRINCIPLES  AND  PRACTICE 
OF  GYNAECOLOGY,  for  the  use  of  Students  and  Practitioners.  Sec- 
ond edition,  enlarged  and  revised.  In  one  large  Svo.  vol.  of  875 
pp. ,  with  136  original  illustrations.  Cloth,  $5;  leather,  $6.  {Just 
ready. ) 


HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS.  5 

EB.ICHSEN  (JOHN  E.)  THE  SCIENCE  AND  ART  OF  SURGERY. 
A  new  and  improved  American,  from  the  Seventh  enlarged  and 
revised  London  edition.  Revised  by  the  Author.  Illustrated  with 
863  engravings  on  wood.  In  two  large  8vo.  vols.  Cloth,  $8  50; 
leather,  raised  bands,  $10  60.      (Just  issited.) 

ENC^CLOP.ffiDIA  OF  GEOGRAPHY.  In  three  large  8vo.  vols.  Illus- 
trated with  8.3  maps  and  about  1100  wood-cuts.     Cloth,  $5. 

FOSTER  (MICHAEL).  TEXT-BOOK  OF  PHYSIOLOGY.  A  new 
American,  from  the  third  English  edition.  Edited,  with  notes  and 
additions,  by  Edward  T.  Reichart,  M.D.  In  one  handsome  12mo. 
vol  of  over  1000  pp.,  with  259  illus.  Cloth,  $2  50;  leather,  $3  25. 
{Just  ready.) 

FINLAYSON  (JAMFS).  CLINICAL  MANUAL  FOR  THE  STUDY 
OF  MEDICAL  CASES.  In  one  handsome  8vo.  vol.  with  numerous 
illustrations.     Cloth,  $2  63.      {Jicst  ready.) 

FOTHERGILL'S  PRACTITIONER'S  HANDBOOK  OF  TREATMENT. 
In  one  handsome  8vo.  vol.  of  about  550  pp.   Cloth,  $4.   {Justi  ssued) 

ON  THE  ANTAGONISM  OF  THERAPEUTIC  AGENTS.     In 

one  neat  12mo.  vol.  of  about  200  pages.     Cloth,  $1.      (Just  issued.) 

FARQUHARSON  (ROBERT).  A  GUIDE  TO  THERAPEUTICS. 
Seeood  American  edition,  revised  by  the  author.  Edited,  with  ad- 
ditions, embracing  the  U.  S.  Pharmacopoeia,  by  Frank  Woodbury, 
M.D.   In  one  neatroyal  ]2mo.  volume.   Cloth,  $2  25.    (NowReady.) 

FENWICK    (SAMUEL).     THE    STUDENTS'   GUIDE    TO  MEDICAL 
DIAGNOSIS.     From  the  Third  Revised  and  Enlarged  London  Edi- 
tion.    In  one  vol.  royal  12mo.     Cloth,  $2  25. 
■pax  (TILBURY).     EPITOME  OF  SKIN  DISEASES,  with   Formula) 
•'-      for  Studentsand  Practitioners.     Second  Am.  Edition,  revised  by  the 
author.     In  one  small  12mo.  vol.     Cloth,  $L38.     {Now  ready.) 

FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE.  Fourth  edition,  thoroughly  revised 
and  enlarged.  In  one  large  8vo.  volume  of  1070  pages.  Cloth,  $6  ; 
leather,  raised  bands,  $7.     {Lately  issued.) 

CLINICAL    MEDICINE.     A    SYSTEMATIC    TREATISE    ON 

THE  DIAGNOSIS  AND  TREATMENT  OF  DISEASE.  Designed 
for  Students  and  Practitioners  of  Medicine.  In  one  handsome  8vo. 
vol.  of  about  900  pages.     Cloth,  $4  50;  leather,  $5  50.   {Just  Ready.) 

A  MANUAL  OF  PERCUSSION  AND  AUSCULTATION;  of  the 

Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  a"nd  of  Tho- 
racic Aneurism.  Second  edition,  revised  and  enlarged.  In  one 
handsome  royal  12mo.  volume.     Cloth,  $1  63. 

MEDICAL  ESSAYS.     In  one  neat  12rao.  volume.     Cloth,  $138. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DISEASES 
AFFECTING  THE  RESPIRATORY  ORGANS.  Second  and  revised 
edition.     One  8vo.  vol.  of  595  pages.     Cloth,  $4  50. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS  AND  TREAT- 

MENT  OF  DISEASES  OF  THE  HEART.  Second  edition,  enlarged. 
In  one  neat  8vo.  vol.  of  over  500  pages,  $4  00. 

ON  PHTHISIS  :  ITS  MORBID  ANATOMY,  ETIOLOGY,  etc., 


in  a  series  of  Clinical  Lectures.    A  new  work.    In  one  handsome  8vo. 
volume.     Cloth,  $3  50. 

FOWNES  (GEORGE).  A  MANUAL  OF  ELEMENTARY  CHEMISTRY. 
A  new  American,  from  the  enlarged  English  edition.  In  one  royal 
12mo.  vol.  of  over  1000  pages,  with  177  illustrations,  and  one  col- 
ored plate.     Cloth,  $2  75  ;  leather,  $3  25.      (Jtcst  issued.) 


HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 


PTJLLE^   (HENEY).     ON    DISEASES  OF   THE   LUNGS   AND  AIR 
-t      PASSAGES.     Their  Pathology,  Physical  Dingnosis,  Symptoms,  and 

Tre.itinent.     From   the  second  English   edition.     In   one  8vo    vol. 

of  about  500  pages.     Cloth,  $3  60. 

GALLOWAY  (RuUJblRT),  A  MANUAL  OF  QUALITATIVE  ANAL- 
YSIS. In  one  ]2mo.  vol.,  cloth,  $2  75. 
GLUGE  (GOTTLIEB).  ATLAS  OF  PATHOLOGICAL  HISTOLOGY. 
Translated  by  Joseph  Leidy,  M.D.,  Professor  of  Anatomy  in  the 
University  of  Pennsylvania,  &c.  In  one  vol.  imperial  quarto,  with 
320  copperplate  figures,  pl.'iin  and  colored.     Cloth,  lj;4. 

GREEN  (l\  HENR'V).  AN  INTRODUCTION  TO  PATHOLOGY  AND 
MORBID  ANATOMY.  Third  Amer.,  from  the  fourth  Lond.  Ed. 
In  one  handsome  8vo.  vol.,  with  numerous  illust.  Cloth,  $2  25. 
(Now  ready  ) 

GRAY  (HENRY).  ANATOMY,  DESCRIPTIVE  AND  SURGICAL. 
A  new  American,  from  the  eighth  and  enlarged  London  edition.  To 
which  is  added  Holden's  "Landmarks,  Medical  and  Surgical."  In  one 
Large  imperial  Svo.  vol.  of  nearly  1000  pages,  with  522  large  and  elabo- 
rate engravings  on  wood.  Cloth,  $6;  leather,  $7.  [Jitst  issued.) 
GRTENE'S  (WILLIAM  H).  A  MANUAL  OF  MEDICAL  CHEMIS- 
TRY. For  the  Use  of  Students.  Based  upon  Bowman's  Medical 
Chemistry,  in  one  royjtl  12mo.  vol.  of  312  pages,  with  72  illustra- 
tions. Cloth,  $1  75.  {Ju it  ready.) 
GRIFFITH  (ROBERT  E.)  A  UNIVERSAL  FORMULARY,  CON- 
TAINING THE  METHODS  OF  PREPARING  AND  ADMINISTER- 
ING OFFICINAL  AND  OTHER  MEDICINES.  Third  and  Enlarged 
Edition.  Edited  by  John  M.  Maiseh.  In  one  large  Svo  vol  of  SCO 
pages,  double  columns.     Cloth,  $4  50  ;  leather,  $5  60. 

GROSS  (SAMUEL  D.)  A  SYSTEM  OF  SURGERY,  PATHOLOGICAL, 
DIAGNOSTIC,  THERAPEUTIC,  AND  OPERATIVE.  Illustrated 
by  1403  engravings.  Fifth  edition,  revised  and  improved.  In  two 
large  imperial  Svo.  vols,  of  over  2200  pages,  strongly  bound  in 
leather,  raised  bands,  $15. 

GROSS  (SAMUEL  D.)  A  PRACTICAL  TREATISE  ON  THE  Dis- 
eases, Injuries,  and  Malformations  of  the  Urinary  Bladder,  the  Pros- 
tate Gland,  and  the  Urethra.  Third  Edition,  thoroughly  Revised 
and  Condensed,  by  Samuel  W.  Gross,  M.D.  In  one  handsome 
octavo  volume,  with  about  200  illus.    Cloth,  $4  60.     (Lively  issned.) 

A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN   THE 

AIR  PASSAGES.     Inone  Svo.  vol.  of  4(58  pages.     Cloth,  $2  75. 

GIBiJN'S  INSTITUTES  AND  PRACTICE  OF  SURGERY.    In  two  Svo. 
vols,  of  about  1000  pages,  leauner,  $6  50. 
HAMILTON    (ALLAN    McLANE).     NERVOUS   DISEASES,    THEIR 
DESCRIPTION  AND  TREATMENT.     In  one  handsome  Svo  vol. 
of  512  pages,  with  53  illustrations.     Cloth,  $3  50.      [Jusl  iss2ied.) 

HEATH  fCHRISTOPHEli).  PRACTICAL  ANATOMY  ;  A  MANUAL 
OF  DISSECTIONS.  With  additions,  by  W.  W.  Keen,  M.  D.  In  1 
volume;  with  247  illustrations.     Cloth,  $3  50;  leather,  $4. 

HARTSHORNE  (HENRY).  ESSENTIALS  OF  THE  PRINCIPLES 
AND  PRACTICE  OF  MEDICINE.  Fourth  and  revised  edition. 
In  one  12mo.  vol.    Cloth,  $2  63;  half  bound,  $2  88.    {Lately  issued  ) 

CONSPECTUS  OF  THE  MEDICAL   SCIENCES.      Comprising 

Manuals  of  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Prac- 
tice of  Medicine,  Surgery,  and  Obstetrics.  Second  Edition.  In  one 
royal  12mo.  volume  of  over  1000  pages,  with  477  illustrations. 
Strongly  bound  in  leather,  $5  00  ;  cloth.  $4  25.     {Lately  issued.) 

., A  HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.     In  one 

aeat  royal  12mo.  volume,  with  many  illustrations.     Cloth.  $1  76. 


HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS.  7 

HABERSHON  (S.  0).  ON  THE  DISEASES  OF  THE  ABDOMEN. 
Second  American,  from  the  third  English  edition.  In  one  Jwml.^nme 
8vo.  volume  of  over  500  pages,  with  illustrations.  Cloth,  $3.50. 
{Now  ready.) 

HOLMES  (TIMOTHY).  SURGERY,  ITS  PRINCIPLES  AND  PRAC- 
TICE. In  one  handsome  8vo.  volume  of  1000  piiges,  with  41 1  illus- 
trations. Cloth,  $6;  leather,  with  raised  bands,  §7.  (Latfh/ issTed.) 
HAlVilLTiiN  (FRAUK  H.)  A  PRACTICAL  TREATISE  UN  FRAC- 
TURES AND  DISLOCATIONS.  Fifth  edition,  carefully  revised. 
In  one  handsome  8vo.  vol.  ot  830  pages,  with.  344  illustrations.  Cloth, 
$5  75  ;   leather,  $6  75. 

HOBLYN  (RICHARD  D.)  A  DICTIONARY  OF  THE  TERMS  USED 
IN  MEDICINE  AND  THE  COLLATERAL  SCIENCES  In  one 
12mo.  volume,  of  over  500  double-columned  pages.  Cloth,  §150; 
leather,  §2. 
TTOLD  N  (LUTHER).  LANDMARKS,  MEDICAL  AND  SURGICAL. 
-•-•-  From  ihe  Second  English  Edition.  In  one  royal  12mo.  vol.  of  128 
pages.     Cloth,  88  cents.      {^Lately  issued.) 

HUDSON  (4.)  LECTURES  ON  THE  STUDY  OF  FEVER.  1  vol. 
8vo.,  316  pages.  Cloth,  S2  50. 
HODGE  rq:UGH  L.)  ON  DISEASES  PECULIAR  TO  AVOMEN,  IN- 
CLUDING DISPLACEMENTS  OF  THE  UTERUS.  Second  and 
revised  edition.  In  one  Svo.  volume.  Cloth,  S4  50. 
THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  Illus- 
trated with  large  lithographic  plates  containing  159  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large 
quarto  vol.  of  550  double-columned  pages.  Strongly  bound  in  cloth, 
S14. 

HOLL.AND  (SIR  HENEY).  MEDICAL  NOTES  AND  REFLECTIONS. 
From  the  third  English  edition.  In  one  8vo.  vol.  of  about  500  pages. 
Cloth,  .$3  50. 

HUGHES.      SCRIPTURE    GEOGRAPHY   AND   HISTORY,    with    12 
colored  maps.     In  1  vol.  12mo.     Cloth,  $1. 
ITORNER  (WILLIAM  E.)     SPECIAL  ANATOMY  AND  HISTOLOGY. 
■•-*•   Eic;hth  edition,  revised  and  modified.     In  two  large  Svo.  vols,  of  over 
1000  pages,  containing  300  wood-cuts.     Cloth,  $li. 

HILL  (BERKEIET?).     SYPHILIS  AND  LOCAL  CONTAGIOUS  DIS- 
ORDERS.    In  one  Svo.  volume  of  467  pages.     Cloth,  §3  25. 
HILLIER  (THOMAS).     HAND-BOOK  OF  SKIN  DISEASES.     Second 
Edition.     In  one  neat  royal  12mo.  volume  of  about  300  pp.,  with  two 
plates.     Cloth,  $2  25. 

HALL  (TiffRS.  M.)    LIVES  OF  THE  QUEENS  OF  ENGLAND  BEFORE 
THE  NORMAN  CONQUEST.     In  one  handsome  Svo.  vol.      Cloth, 
$2  25;  crimson  cloth,  §2  50  ;  half  morocco,  83. 
TONES  (0.  HANDFIELD).     CLINICAL  OBSERVATIONS  ON  FUNC- 
O       TIONAL  NERVOUS  DISORDERS.     Second  American  Edition.     In 
one  Svo.  vol.  of  348  pages.     Cloth,  §3  25. 

KNAPP  (F.)  TECHNOLOGY;  OR  CHEMISTRY,  APPLIED  TO  THE 
ARTS  AND  TO  xMANUFACTURES,  with  American  additions,  by 
Prof.  Walter  R.  Johnson.    In  two  Svo.  vols.,  with  500  ill.    Cloth.'$6. 

KENNEDY'S  MExMOIRS  OF  THE  LIFE  OF  WILLIAM  AVIRT.  In 
two  vols.  12mo.     Cloth,  $2. 

LAURENCE  (J.  Z.)  AND  MOON  (ROBERT  C.)  A  HANDY-BOOK 
OF  OPHTHALxMIC  SURGERY.  Second  edition,  revi.=ed  by  Mr. 
Laurence.     With  numerous  illus.     In  one  Svo.  vo'.     Cloth,  $2  75. 


8  HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

T  EE  (HENRY)  ON  SYPHILIS.     In  one  8vo.  voL     Cloth,  $2  25. 

LEA  (HENRY  C.)  SUPERSTITION  AND  FORCE  ;  ESSAYS  ON  THE 
WAGER  OP  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL, 
AND  TORTURE.  Third  edition,  thoroughly  revised  and  enlarged. 
In  one  handsome  royal  12mo.  vol.     Cloth,  $2  60.      (Just  issued.) 

— : STUDIES  IN  CHURCH  HISTORY.     The  Rise  of  the  Temporal 

Power — Benefit   of  Clergy — Excommunication.     In  one   handsome 
12mo.  vol.  of  515  pp.     Cloth,  $2  75. 
AN  HISTORICAL   SKETCH    OF   SACERDOTAL  CELIBACY 


L 


IN  THE  CHRISTIAN  CHURCH.     In  one  handsome  octavo  volume 
of  602  pages.     Cloth,  $3  75. 
A  ROCHE  (R.)     YELLOW  FEVER.     In  two  8vo.  vols,  of  nearly  1500 
pages.     Cloth,  $7. 
—  PNEUMONIA.    In  one  8vo.  vol.  of  500  pages.     Cloth,  $3. 


LEISHMAN  (WILLIAM).  A  SYSTEM  OF  MIDWIFERY.  Includ- 
ing the  Diseases  of  Pregnancy  and  the  Puerperal  Stiite.  Third 
American,  from  the  Third  Englieh  Edition.  With  additions,  by 
J.  S.  Parry,  M.D.  In  one  very  handsome  8vo.  vol.  of  nearly  800 
pnges  and  over  200  illustrations.  Cloth,  $4  50;  leather,  $5  50. 
(Just  ready.) 

LEHMANN  (C.  G.)  PHYSIOLOGICAL  CHEMISTRY.  Translated  by 
George  P.  Day,  M.D.  With  plates,  and  nearly  200  illustrations. 
In  two  large  8vo.  vols.,  containing  1200  pnges.     Cloth,  $6. 

A    MANUAL   OF    CHEMICAL   PHYSIOLOGY.     In   one   very 

handsome  8vo.  vol.  of  336  pages.     Cloth,  $2  25. 

LAWSON  (GEORGE).  INJURIES  OF  THE  EYE,  ORBIT,  AND  EYE- 
LIDS, with  about  100  illustrations.  From  the  last  English  edition. 
In  one  handsome  8vo.  vol.     Cloth,  $3  50. 

LUDLOW  (J.  L.)  A  MANUAL  OF  EXAMINATIONS  UPON  ANA- 
TOMY, PHYSIOLOGY,  SURGERY,  PRACTICE  OF  MEDICINE, 
OBSTETRICS,  MATERIA  MEDICA,  CHEMISTRY,  PHARMACY, 
AND  THERAPEUTICS.  To  which  is  added  a  Medical  Formulary. 
Third  edition.  In  one  royal  12mo.  vol.  of  over  800  pages.  Cloth, 
$3  26;   leather,  $3  75. 

LYNCH  (W.  F.)     A  NARRATIVE  OF  THE  UNITED  STATES  EX- 
PEDITION TO  THE  DEAD  SEA  AND  RIVER  JORDAN.     In  one 
large  octavo  vol.,  with  28  beautiful  plates  and  two  maps.    Cloth,  $3. 
Same  Work,  condensed  edition.    One  vol.  royal  12mo.    Cloth,  $1. 

LYONS  (ROBERT  D.)  A  TREATISE  ON  FEVER.  In  one  neat  8vo. 
vol.  of  362  pages.     Cloth,  $2  26. 

MEIGS  (CHAS.  D).    ON  THE  NATURE,  SIGNS,  AND  TREATMENT 
OF  CHILDBED  FEVER.     In  one  8vo.  vol.  of  365  pages.     Cloth,  $2. 
MILLER  (JAMES).    PRINCIPLES  OF  SURGERY.    Fourth  American, 
from  the  third  Edinburgh  edition.      In  one  large  8vo.  vol.  of  700 
pages,  with  240  illustrations.     Cloth,  $3  75. 

THE  PRACTICE  OF  SURGERY.     Fourth  American,  from  the 

last  Edinburgh  edition.  In  one  large  8vo.  vol.  of  700  pages,  with 
364  illustrations.     Cloth,  $3  75. 

MONTGOMERY  (W.  F.)  AN  EXPOSITION  OF  THE  SIGNS  AND 
SYMPTOMS  OF  PREGNANCY.  From  the  second  English  edition. 
In  one  handsome  8vo.  vol.  of  nearly  600  pages.     Cloth,  $3  75. 

MORRIS  (MALCOLM).  SKIN  DISEASES:  Including  their  Defini- 
tions, Symptoms,  Diagnosis,  Prognosis,  Morbid  Anatomy,  and 
Treatment.  A  Manual  for  Students  and  Practitioners.  In  one 
12mo.  vol.  of  over  300  pages,  with  illustrations.  Cloth,  $1  75. 
(Just  ready.) 


HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 


MULLEE  (I.)     PRINCIPLES  OP  PHYSICS  AND  METEOROLOGY. 
In  one   large  Svo.  voL  with  550  wood-cuts,  and  two  colored  plates. 
Cloth,  $4  50. 
TV/rillABEATJ  ;   A  LIFE  HISTORY.     In  one  12mo.  voL     Cloth,  75  cts. 

MACFARLAND'S  TURKEY  AND  ITS  DESTINY.     In  2  vols,  royal 
12ino.     Cloth,  $2. 
MA.T?SH  (MRS.)     A  HISTORY  OP  THE  PROTESTANT  REFORMA- 
TION IN  FRANCE.     In  2  vols,  royal  12mo.     Cloth,  $2. 

NEILL  (TOHN)  AND  SMITH  (FRANCIS  G.)  COMPENDIUM  OF 
THE  VARIOUS  BRANCHES  OF  MEDICAL  SCIENCE.  In  one 
hnnd?ome  12aT0.  vol.  of  about  1000  pages,  with  374  wood-cuts. 
Cloth,  S4;  leather,  raised  bands,  S4  75. 

NETTLESHIP'S  MANUAL  OF  OPHTHALMIC  MEDICINE.  In 
one  royal  12rao.  vol.  of  over  3£0  pp.,  with  89  illustritions.  Cloth, 
$2.      {J/ist  ready.) 

PLAYFAIR  (W.  S.)  A  TREATISE  ON  THE  SCIENCE  AND  PRAC- 
TICE OF  MIDWIFERY  Third  Amerieiin  Edition,  revised  by  the 
author.  Edited,  with  Additions,  by  R.  P.  Harris,  M.D.  In  one 
handsome  octavo  vol.  of  about  700  pages,  with  nearly  200  illustra- 
tions and  two  plates.  Cloth,  f4:  leather,  S5  (Juft  renr/y. .) 
PAVY  (F.  W.)  A  TREATISE  ON  THE  FUNCTION  OF  DIGESTION, 
ITS  DISORDERS  AND  THEIR  TREATMENT.  From  the  second 
London  ed.     In  one  8vo.  vol.  of  240  pp.     Clcith,  $2. 

PAERISH  (EDWARD).  A  TREATISE  ON  PHARMACY.  With  many 
Formulae  and  Prescriptions.  Fourth  edition.  Enlarged  and  thoroughly 
revised  by  Thomas  S.  Wiegand.  In  one  handsome  8vo.  vol.  of  977 
pages,  with  280  illus.     Clcth,  $5  50  ;  leather,  §6  50. 

PIRRTE  (WILLIAM)  THE  PRINCIPLES  AND  PRACTICE  OF  SUR- 
GERY. In  one  handsome  octavo  volume  of  780  pages,  with  316 
illustrations.     Cloth,  $3  75. 

PULSZKY'S  MEMOIRS  OF  AN  HUNGARIAN  LADY.  In  one  neat 
royal  12mo.  vol.     Cloth,  $1. 

PAGET'S  HUNGARY  AND  TRANSYLVANIA.     In  two  royal  12mo. 
vols.     Cloth,  $2, 
REYNOLDS  (J.  RUSSELL)      A  SYSTEM  OF  MEDICINE,  wilh  Notes 
and  Additiars.  by  Henrt  Hartshorne,  M  D.     In  three  large  8vo. 
vols.,  containing  about  3000  closely  printed  double-columned  pages, 
•  with  many  illustrations.      Sold  only  by  subscription.      Per  vol.,  in 
cloth.  $5  ;  in  leather,  $fi.      (Just  ready.) 
■pEMSEN  (IRA).     THE   PRINCIPLES    OF    CHEMISTRY.      In  one 
■'-*'     handsome  12mo.  vol.      Cloth,  SI  50.      {Just  iss?ied.) 

ROBERTS  (WILLIAM).  A  PRACTICAL  TREATISE  ON  URINARY 
AND  RENAL  DISEASES.  Third  American,  from  the  third  re- 
vised and  enlarged  London  edition.  AVith  numerous  illustrations 
and  a  colored  plate.  In  one  very  handsome  8vo.  vol,  of  over  6G0 
pages.  Cloth,  $4. 
■p  ATMS  BOTH  AM  (FRANCIS  H.)  THE  PRINCIPLES  AND  PRAC- 
H  TICE  OF  OBSTETRIC  MEDICINE  AND  SURGERY.  In  oneim 
pevial  8vo.  vol.  of  650  pages,  with  64  plates,  besides  numerous  wood- 
cuts in  the  text.     Strongly  bound  in  leather,  S7. 

RANKE'S    HISTORY    OF    THE    REFORMATION    IN    GERMANY. 
Parts  I.,  II.,  III.     In  one  vol.     Cloth,  §1. 


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10  HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

■piGBY  (EDWARD).     A  SYSTEM  OF  MIDWIFERY.     Second  Ameri. 
•t*'    can  edition.    In  onehandsome  8vo.  vol.  of  422  pages.    Cloth,  $2  50. 

SEILER  (CARL)  HANDBOOK  OF  DIAGNOSIS  AND  TREATMENT 
OF  DISEASES  OP  THE  TIIkOAT  AND  NASaL  CAVITIES.  In 
one  small  12mo.  vol  ,  with  illustrations.     Cloth,  $1.     (Now  Ready.) 

S CHAFER  (EDWARD  ALBERT).  A  COURSE  OF  PRACTICAL  HIS- 
TOLOGif  :  A  Manual  of  the  Microscope  for  Medical  Students.  In 
onehandsomeoctavo  vol.  With  many  illust.  Cloth,  $2.    (Just  Issiied.) 

QNMITH  (TiENRY  H.)  AND  HORNER  (WILLIAM  E.)     ANATOMICAL 
•^     ATLAS.  Illustrative  of  thestructure  ofthe  Human  Body.  In  one  large 
imperial  8vo.  vol.,  with  about  650  beautiful  figures.     Cloth,  $4  60. 

TIMSON  (LEWIS  A.)  A  MANUAL  OF  OPERATIVE  SURGERY. 
In  one  very  handsome  royal  12mo  volume  of  488  pages,  with  332 
illustrations.     Cloth,  $2  50.     (Just  issued.) 

S WAYNE  (JOSEPH  GRIFFITHS).  OBSTETRIC  APHORISMS.  A 
new  American,  from  the  fifth  revised  English  edition.  With  addi- 
tions by  E.  R.  Hutchins,  M.  D.  In  one  small  12mo.  vol.  of  177  pp., 
with  illustrations.     Cloth,  $1  25. 

QTITRGES    (OCTAVIUS).     AN    INTRODUCTION    TO   THE    STUDY 
fJ     OF  CLINICAL    MEDICINE.      In  one   12mo.  vol.      Cloth,  $1  25. 

OMITH  (EUSTACE).  ON  THE  WASTING  DISEASES  OF  CHILDREN. 
'^     Second  American  edition,  enlarged.     In  one  8vo.  vol.     Cloth,  $2  50. 

SARGENT  (F,  V7,)  ON  BANDAGING  AND  OTHER  OPERATIONS 
OF  MINOR  SURGERY.  New  edition,  with  an  additional  chapter 
on  Military  Surgery.  In  one  handsome  royal  12mo.  vol.  of  nearly 
400  pages,  with  184  wood-cuts.     Cloth,  .SI  75. 

SMITH  (J.  LEWIS).  A  TREATISE  ON  THE  DISEASES  OF  IN- 
FANCY AND  CHILDHOOD.  Fourth  Edition,  revised  and  enlarged. 
In  one  large  Svo.  volume  of  758  pages,  with  illustrations.  Cloth, 
$4  50;   leather,  $5  50.      (Nowready.) 

SHARPEY  (WILLIAM)  AND  QUAIN  (JONES  AND  RICHARD). 
HUMAN  ANATOMY.  With  notes  and  additions  by  Jos.  Leidy, 
M.D.,  Prof,  of  Anatomy  in  the  Univ?rsity  of  Pennsylvania.  In  two 
large  Svo.  vols,  of  about  1300  pages,  with  5]  1  illustrations.     Cloth,  $6. 

SCHMITZ  AND  ZUMPT'S  CLASSICAL  SERIES.     In  royal  18mo. 
CORNELII  NEPOTIS  LIBER  DE  EXOELLENTIBUS  DUCIBUS 
EXTERARUM  GENTIUM,  CUM  VITIS  CATONIS  ET  ATTICI. 
With  notes,  &c.     Price  in  cloth,  60  cents  ;  half  bound,  70  cts. 

C,  C.  SALLUSTII  DE  BELLO  CATILINARIO  ET  JUGURTHINO 
With  notes,  map,  &c.     Price  in  cloth,  60  cents  ;  half  bound,  70  cents 

Q.  CURTII  RUFII  DE  GESTIS  ALEXANDRI  MAGNI  LIBRI  VIII. 
With  notes,  map,  &c.     Price  in  cloth,  80  cents  ;  half  bound,  90  cents. 

P.  VIRGILII   MARONIS    CARMINA   OMNIA.     Price  in  cloth,  85 

cents;  half  bound,  $1. 
ADVANCED    LATIN    EXERCISES,     WITH     SELECTIONS    FOR 

READING.     Revised.     Cloth,  price  60  cents  ;  half  bound,  70  cents 

SKEY  (FREDERIC  C.)  OPERATIVE  SURGERY.  In  one  Svo.  vol. 
of  over  650  pages,  with  about  100  wood-cuts.     Cloth,  $3  25. 

SLADE  (D.  D.)  DIPHTHERIA  ;  ITS  NATURE  AND  TREATMENT. 
Second  edition.     In  one  neat  royal  12mo.  vol.     Cloth,  $1  25. 


HENRY  C.  LExl'S  SON  &  CO."S  PUBLICATIONS.  11 

SMITH  (EDWARD).  CONSUMPTION;  ITS  EARLY  AND  REME- 
DIABLE STAGES.     In  one  8vo.  toL  of  254  pp.     Cloth,  $2  25. 

STILLE  (ALFRED).  THERAPEUTICS  AND  MATERIA  MEDIC  A. 
FoTirth  edition,  revised  and  enlarged.  In  two  large  and  handsome 
volumesSvo.     Cloth,  $10  ;  leather,  $12.     (Just  issued.) 

STILLE  (ALFRED)  AND  MAISCH  (JOHN  M  )  THE  NATIONAL 
DISPENSATORY:  Embracing  the  Chemistry,  Botany,  Materia 
Medica,  Pharmscv,  Pharniaeodynamic.*,  and  Therapeutics  of  the 
Pbarmaeopoeias  of  the  United  States  and  Great  Britain.  For  the 
Use  of  Physicians  and  Pharmaceutists.  Second  edition,  revised 
and  enlarged.  In  one  handsome  8vo.  vol.,  of  IfiSO  pages,  with  239 
illustrations.    Cloth,  $6  75;   leather,  $7  50.      [Now  ready.) 

OMAIL  BOOKS  ON  GREAT  SUBJECTS.     In  3  vols.     Cloth,  $1  50. 

SCHOEDLER  (FREDERICK)  AND  MEDLOCK  (HENRY).  WONDERS 
OF  NATURE.  An  elementary  introduction  to  the  Sciences  of  Ph^-sics, 
Astronomy,  Chemistry,  Mineralogy,  Geology,  Botany.  Zoology, 
and  Physiology.  Translated  from  the  German  by  H.  Medlock.  In 
one  neat  8vo.  vol.,  with  679  illustrations.     Cloth,  S3. 

OTOKES  (W.)     LECTURES  ON  FEVER.    InoneSvo.  vol.    Cloth,  $2. 

STRICKLAND  (AGNES).  LIVES  OF  THE  QUEENS  OF  HENRY 
THE  VIII.  AND  OF  HIS  MOTHER.  In  one  crown  octavo  vol., 
extra  cloth,  SI ;  black  cloth,  90  cents. 

MEMOIRS  OF  ELIZABETH,  SECOND  QUEEN  REGNANT  OF 

ENGLAND  AND  IRELAND.     Inonecrown  octavo  vol.,  extra  cloth, 
$1  40;  black  cloth,  $1  30. 

TANNER  (THOMAS  HAWKES) .  A  MANUAL  OF  CLINICAL  MEDI- 
CINE AND  PHYSICAL  DIAGNOSIS.  Third  American  from  the 
second  revised  English  edition.  Edited  by  Tilbury  Fox,  M.D.  In 
one  handsome  12mo.  volume  of  366  pp.     Cloth,  $1  50. 

ON   THE   SIGNS  AND  DISEASES  OF  PREGNANCY.     From 

the  second  English  edition.  With  four  colored  plates  and  numerous 
illustrations  on  wood.  In  one  vol.  8vo.  of  about  500  pages.  Cloth 
.S4  25. 

TUKE  (DANIEL  HACK).  INFLUENCE  OF  THE  MIND  UPON  THE 
BODY.     In  one  handsome  8vo.  vol.  of  416  pp.     Cloth,  $3  25. 

rPAYLOR    (ALFRED    S.)     MEDICAL    JURISPRUDENCE.     Seventh 
-'•     American  edition.     Edited  by  John  J.  Reese,  M.D.     In  one  large 
Svo.  volume  of  879  pages.     Cloth,  S5;  leather,  $6.      {J2<st  iss7/ed.) 
PRINCIPLES  AND   PRACTICE    OF    xMEDICAL   JURISPRU- 
DENCE.    From  the  Second  English  Edition.      In  two  large  Svo. 
vols.     Cloth,  $10  ;  leather,  $12.      {.htst  issued.) 

ON  POISONS  IN  RELATION  TO  MEDICINE  AND  MEDICAL 

JURISPRUDENCE.     Third  American  from  the  Third  London  Edi- 
tion.    1  vol.  Svo.  of  788  pages,  with  104  illustrations.     Cloth,  $5  50 
leather,  $6  50.      {Just  issued.) 

THOMAS  (T.  GAILLARD).  A  PRACTICAL  TREATISE  ON  THE 
DISEASES  OF  FEMALES.  Fourth  edition,  thoroughly  revised. 
In  one  large  and  handsome  octavo  volume  of  801  pages,  with  191 
illustrations.     Cloth,  $5  00;  leather,  $6  00.     {Jiist issued.) 

TODD  (ROBERT  BENTLEY) .  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.    In  one  vol.  Svo.  of  320  pp.,  cloth,  $2  50. 


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12  HENRY  C.  LEA'S  SON  &  CO.'S  PUBLICATIONS. 

THOMPSON  (SIR  HENRY).  THE  PATHOLOGY  AND  TREATMENT 
OF  STRICTURE  OF  THE  URETHRA  AND  URINARY  FISTUL^E. 
From  tlie  third  English  edition.  In  one  8vo.  vol.  of  359  pp.,  with 
illustrations.     Cloth,  $3  50. 

THOMPSON  (SIR  HENRl^).  CLINICAL  LECTURES  ON  DISEASES 
OF  THE  URINARY  ORGANS.  Second  and  revised  edition.  In 
one  8vo.  volume,  with  illustrations.     Cloth,  $2  25.      (Just  issued.) 

WALSHE  (W.  H.)  PRACTICAL  TREATISE  ON  THE  DISEASES 
OF  THE  HEART  AND  GREAT  VESSELS.  Third  American  from 
the  third  revised  London  edition.  In  one  8vo.  vol.  of  420  pages. 
Cloth,  $3. 

ATSON  (THOMAS),  LECTURES  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  PHYSIC.  A  new  Americiui  from  the  fifth  and  en- 
larged English  edition,  with  additions  by  H.  Hartshorne,  M.D.  In 
two  large  and  handsome  octavo  volumes.     Cloth,  $9;  leather,  $11. 

OHLER'S  OUTLINES  OF  ORGANIC  CHEMISTRY.  Translated 
from  the  Sth  German  edition,  by  Ira  Remsen,  M.D.  In  one  neat 
12mo.  vol.     Cloth,  $3  GO.      {Lately  issued.) 

ELLS  (J.  SOELBERG).  A  TREATISE  ON  THE  DISEASES  OF 
THE  EYE.  Third  edition,  enlarged  and  thoroughly  revised  by 
Chas.  S.  Bull,  A.M.,  M.D.  In  one  large  and  handsome  octavo  vol., 
with  6  colored  plates  and  many  wood-cuts,  also  selections  from  the 
tesf-types  of  Jaeger  and  Snellen.     {Preparing.) 

EST  (CHARLES).  LECTURES  ON  THE  DISEASES  PECULIAR 
TO  AVOMEN.  Third  American  from  the  Third  English  edition.  In 
one  octavo  volume  of  550  pages.     Cloth,  $3  75  ;  leather,  $4  75. 

—  LECTURES  ON  THE  DISEASES  OF  INFANCY  AND  CHILD- 
HOOD.  Fifth  American  from  the  sixth  revised  English  edition.  In 
one  large  8vo.  vol.  of  670  closely  printed  pages.  Cloth,  $4  50  ;  lea- 
ther, §5  50.     {Just  issued.) 

ON    SOME    DISORDERS    OF    THE    NERVOUS   SYSTEM   IN 


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CHILDHOOD.  From  the  London  Edition.  In  one  small  12mo. 
volume.     Cloth,  $1. 

WILLIAMS  (CHARLES  J.  B.  and  C.  T.)  PULMONARY  CONSUMP- 
TION :  ITS  NATURE,  VARIETIES,  AND  TREATMENT.  In 
one  neat  octavo  volume.     Cloth,  $2  50. 

ILSON  (ERASMUS).  A  SYSTEM  OF  HUMAN  ANATOMY.  A 
new  and  revised  American  from  the  last  English  edition.  Illustrated 
with  397  engravings  on  wood.  In  one  handsome  8vo.  vol.  of  over 
600  pages.    Cloth,  $4  ;  leather,  $5. 

THE  STUDENT'S  BOOK   OF  CUTANEOUS   MEDICINE.     In 


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one  handsome  royal  12mo.  vol.     Cloth,  $3  50. 

WINCKEL  ON  PATHOLOGY  AND  TREATMENT  OF  CHILDBED. 
AVith  Additions  by  the  Author.  Translated  by  Chadwick.  In  one 
handsome  octavo  volume  of  484  pages.     Cloth,  $4.     (Just  issiced.) 

WOODBURY  (FRANK).  A  HANDBOOK  OF  THE  PRINCIPLES 
AND  PRACTICE  OF  MEDICINE.  In  one  royal  12mo.  volume. 
{Prepaiing.) 


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DUE  DATE 

-^ 

SEP  3  0 

1991    OC 

'  2  riS?T 

nffl 

iJOV    6 

iqgi 

Printed 
in  USA 

COLUMBIA  UNIVERSITY  LIBRARIES 


0022313320 


